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Performance audit, Board of Nursing

Performance audit, Board of Nursing

State of Arizona
Office
of the
Auditor General
PERFORMANCE AUDIT
Report to the Arizona Legislature
By Debra K. Davenport
Auditor General
BOARD
OF
NURSING
September 2001
Report No. 01-21
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee
composed of five senators and five representatives. Her mission is to provide independent and impar-tial
information and specific recommendations to improve the operations of state and local government
entities. To this end, she provides financial audits and accounting services to the state and political
subdivisions and performance audits of state agencies and the programs they administer.
The Joint Legislative Audit Committee
Senator Ken Bennett, Chairman
Representative Roberta L. Voss, Vice-Chairman
Senator Herb Guenther Representative Robert Blendu
Senator Dean Martin Representative Gabrielle Giffords
Senator Peter Rios Representative Barbara Leff
Senator Tom Smith Representative James Sedillo
Senator Randall Gnant (ex-officio) Representative James Weiers (ex-officio)
Audit Staff
Dale Chapman—Manager
and Contact Person (602) 553-0333
Ann Orrico—Team Leader
Joseph McKersie—Team Member
Kristin Borns—Team Member
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
(602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
September 12, 2001
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Ms. Joey Ridenour, Executive Director
Arizona State Board of Nursing
Transmitted herewith is a report of the Auditor General, A Performance Audit of the Board of
Nursing. This report is in response to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. The performance audit was conducted as part of the Sunset review set forth in
A.R.S. §41-2951 et seq. I am also transmitting with this report a copy of the Report Highlights
for this audit to provide a quick summary for your convenience.
As outlined in its response, the Board of Nursing agrees with all of the findings and plans to
implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on September 13, 2001.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
OFFICE OF THE AUDITOR GENERAL
Program Fact Sheet
Board of Nursing
Services: The Board of Nursing (Board) is responsible for regulating nurses and certified
nursing assistants (CNAs) through licensure and certification. The Board performs the fol-lowing
services: 1) Approving individuals for licensure, registration, and certification; 2)
Approving educational programs for nurses and nursing assistants; 3) Investigating and
adjudicating complaints concerning allegations of unprofessional conduct or other viola-tions
of the Nurse Practice Act; and 4) Providing consumer information to the public.
Program Operations Revenue1:
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
1999 2000 2001
Other(2)
Intergovernmental(3)
Fines and forfeits
Licenses, fees, and permits
1 The Board retains 90 percent of its revenues for oper-ating
and remits all of its administrative penalties and
10 percent of all other revenues into the General Fund.
2 For fiscal year 2000, includes a $320,000 General Fund
appropriation to pay for fingerprinting certified nurs-ing
assistant applicants.
3 Consists of federal monies for nursing assistant certi-fication.
Facilities:
The Board owns no facilities. The Board’s
office is located in a state-owned building
at 1651 E. Morten, in Phoenix. Board meet-ings
are held at this location.
Personnel:
The Board consists of nine members who
serve five-year terms:
n Five registered nurses who have at
least five years’ experience in nursing
following graduation and have been
actively engaged in the practice of
nursing for at least five years prior to
the appointment.
n Two licensed practical nurses who
must also have five years’ nursing
experience and have been actively
engaged in nursing at least three
years prior to the appointment; and
n Two public members who are not
employees of any health care institu-tion
and do not have a financial inter-est
as a provider in the delivery of
health care services.
As of July 1, 2001, the Board had 53.8 full-time
staff:
¾ Administration and Support Staff (23)
¾ Licensing (9)
¾ Investigations/Adjudication (21.8)
OFFICE OF THE AUDITOR GENERAL
Agency Mission:
“To protect the public
health, safety, and welfare
through the safe and com-petent
practice of nursing
and nursing assistants.”
Equipment:
In addition to owning standard office
equipment, the Board also rents a vehicle
from the Department of Administration for
$403 per month.
Program Goals (Fiscal Year 2000-2001):
The Board of Nursing consists of the fol-lowing
two programs:
Licensing and Regulation—RN/LPN:
1. To reduce the cycle time needed to is-sue
certificates and licenses for exami-nee,
endorsement, and renewal appli-cants.
2. To reduce the cycle time needed to in-vestigate
complaints, complete hear-ings,
and increase compliance with
consent agreements and Board orders.
3. To effectively provide a non-disciplinary
Chemically Addicted
Nurse Diversion Option (CANDO)
program.
4. To provide an effective educational
program monitoring process for
schools of nursing that promotes a high
percentage of RN/LPN examinees
passing NCLEX (a national licensure
exam for RNs and LPNs).
Nursing Assistant:
1. To reduce the cycle time needed to is-sue
certificates for examinee, endorse-ment,
and renewal applicants.
2. To reduce the cycle time needed to in-vestigate
complaints, complete hear-ings,
and increase compliance with
consent agreements and Board orders.
Adequacy of Performance Measures:
The Board has established appropriate per-formance
measures within its Licensing
and Regulation—RN/LPN and Nursing
Assistant programs. For example, the
Board has established measures focusing
on its licensing, certification, and complaint
investigation activities; the timeliness and
results of those activities; and customer sat-isfaction
with these efforts.
i
OFFICE OF THE AUDITOR GENERAL
SUMMARY
The Office of the Auditor General has conducted a performance
audit and Sunset review of the Board of Nursing (Board) pursu-ant
to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. This audit was conducted under the authority
vested in the Auditor General by Arizona Revised Statutes
(A.R.S.) §41-2951 et seq.
The Board is responsible for regulating registered nurses (RNs),
licensed practical nurses (LPNs), and certified nursing assistants
(CNAs). The Board’s duties include issuing and renewing li-censes,
conducting investigations and hearings concerning un-professional
conduct, disciplining violators, and providing con-sumer
information to the public. As of July 2001, the Board li-censes
approximately 47,300 RNs, including 2,350 RNs certified
as advanced practice nurses, and 9,320 LPNs and certifies ap-proximately
18,600 CNAs. Further, the Board reports that it re-ceived
approximately 2,200 complaints in fiscal year 2000.
The Board Should Improve
the Timeliness of Its Complaint
Investigations
(See pages 11 through 18)
The Board should take several steps to ensure complaints are in-vestigated
in a timely manner. Auditors’ review of 83 complaint
investigations presented to the Board in fiscal year 2000 for adju-dication
found that the Board’s investigation times ranged from
32 days to 1,938 days, with over half of these investigations tak-ing
longer than 360 days.1 In addition, as of August 2001, the
1 The 83 investigations reviewed did not include investigations that arose as
a result of information disclosed on license/certificate applications or
background checks. When these investigations are combined with com-plaint
investigations, the Board reports that it takes an average of nine to
ten months to complete an investigation.
Summary
ii
OFFICE OF THE AUDITOR GENERAL
Board had approximately 1,750 open investigations, including
hundreds of investigations that were initiated prior to 2000. For
example, 122 investigations initiated in 1997 remain unresolved
as of August 2001. The Board’s long investigation time frames
represent a risk to the public because nurses and CNAs under
investigation can continue to practice for long periods without
receiving appropriate discipline and addressing the identified
problems.
In 1995, the Board received regulatory responsibility for investi-gating
CNA complaints and certification applications. This in-creased
the number of investigations it conducts, and affected
the Board’s ability to investigate complaints in a timely manner.
In fact, of the approximately 1,750 open investigations as of Au-gust
2001, over 1,200 are related to CNAs. To help it complete the
large number of open complaint investigations, the Board re-quested
and received $772,700 over fiscal year 2001 and fiscal
year 2002 to hire nine additional investigators. However, seven
of these investigator positions are temporary and will terminate
after June 2002.
While the Board has hired additional investigative staff, it can
take several other steps to improve its investigation timeliness.
First, the Board should monitor the progress of its additional in-vestigative
staff to ensure that it eliminates as many open inves-tigations
as possible before it loses the seven temporary investi-gators.
Second, the Board should develop and implement inter-nal
time frames for each stage of its investigation process. While
it may take time for the Board to adhere to these time frames be-cause
of the large number of open investigations, the Board
should, at a minimum, ensure that high-priority complaint in-vestigations
(those alleging patient harm) adhere to the estab-lished
time frames. Further, the Board should generate monthly
management reports to ensure that internal time frames are met
and complaints are investigated in a timely manner. Finally, be-cause
the number of complaints ready for adjudication at each
Board meeting will likely increase, the Board should consider
options, such as dividing into two panels or subcommittees or
meeting more frequently, to adjudicate these cases in a timely
manner.
Summary
iii
OFFICE OF THE AUDITOR GENERAL
Board Practices Restrict
Access to Public Information
(See pages 19 through 23)
The Board does not provide appropriate access to public infor-mation
regarding nurses and CNAs. Specifically, auditors posing
as members of the public phoned the Board and requested in-formation
on five different licensees/certificate holders. Two
auditors’ requests were handled appropriately. However, in one
instance, the Board failed to disclose to the auditor the nature of a
pending complaint against a CNA. Further, another auditor was
not informed of a nurse’s dismissed complaint. Finally, one audi-tor
was not able to obtain any complaint or disciplinary informa-tion
despite phone calls and a visit to the Board’s offices. Unim-peded
access to public information about nurses and CNAs is an
important regulatory board function as it helps consumers select
competent and ethical professionals.
In addition, certain Board practices further impede consumers’
access to public information. According to policy, Board staff
must ask consumers for information such as their name, tele-phone
number, and reason for requesting public information.
While the Board has established this practice to protect the safety
of nurses and CNAs because their home addresses may be con-sidered
public information if a business address is not provided,
it may deter consumers from making public information re-quests.
Further, the Board’s automated phone system is difficult
to navigate and does not provide easy access to the appropriate
staff to handle consumers’ requests.
Other Pertinent Information
(See pages 25 through 29)
During the audit, other pertinent information was gathered in
response to legislative inquiries concerning the Board’s regula-tion
of CNAs. The regulation of nursing assistants resulted from
the federal government’s 1987 Omnibus Reconciliation Act (Act).
The purpose of the Act is to protect individuals in nursing homes
and other federally funded long-term care facilities from im-properly
trained nursing assistants. The Act establishes certain
minimum requirements for certifying and regulating nursing
Summary
iv
OFFICE OF THE AUDITOR GENERAL
assistants. To help offset some of the costs of regulating CNAs,
the Act provides federal monies to states, but does not allow
states to charge nursing assistants for certification costs.
Auditors’ review of other states’ CNA regulatory structures
found that Arizona is 1 of 14 states that regulate CNAs through
boards of nursing. Arizona adopted this regulatory structure be-cause
the Board already had established processes for licensing
nurses that could be used for certifying nursing assistants. Other
common regulatory models among the 50 states include health
facility regulatory agencies, such as Indiana’s Department of
Health, Division of Long Term Care, or occupational licensing
and regulatory agencies, such as Alaska’s Division of Occupa-tional
Licensing, which licenses multiple occupations, from acu-puncturists
to public accountants.
While the Board initially struggled with the responsibility of
regulating CNAs because of the increased workload, it has since
received additional resources to help perform its regulatory re-sponsibilities.
For example, the Board has established a fee for
optional CNA cards that show proof of current certification and
has also received State General Fund monies to cover the ex-pense
of fingerprinting CNAs for certification background
checks. In addition, the Board hired more investigators, although
most are temporary positions, to assist it in completing its large
number of open CNA-related investigations.
v
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS
Page
Introduction and Background............................. 1
Finding I: The Board Should
Improve the Timeliness of Its
Complaint Investigations................................ 11
Slow Investigations Decrease
Board’s Public Protection
Efforts.................................................................................. 11
Three Factors Affect Board’s
Ability to Investigate Complaints
In a Timely Manner............................................................ 14
Changes Needed to Improve
Investigation Timeliness and
Reduce Number of Open
Investigations ..................................................................... 16
Recommendations ............................................................. 18
Finding II: Board Practices
Restrict Access to Public
Information ...................................................... 19
Providing Public Information
Is an Important Part of a
Regulatory Board’s Responsibilities.................................. 19
Board Needs To Provide More
Complete Public Information............................................ 19
Board Should Provide Easier
Access To Public Information............................................ 21
Recommendations ............................................................. 23
Table of Contents
vi
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS (Concl’d)
Page
Other Pertinent Information................................. 25
Regulating Certified
Nursing Assistants............................................................. 25
Sunset Factors..................................................... 31
Agency Response
Items
Item 1 Licenses and Certificates
Issued by the Board.......................................... 2
Item 2 Complaint Priorities......................................... 4
Item 3 Open Investigations
As of August 2001
By Year of Receipt............................................ 12
Item 4 Nursing Assistants’ Duties.............................. 25
Table
Table 1 State Board of Nursing
Statement of Revenues, Expenditures,
and Changes in Fund Balance
Years Ended June 30, 1999, 2000, and 2001
(Unaudited)...................................................... 7
1
OFFICE OF THE AUDITOR GENERAL
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance
audit and Sunset review of the Board of Nursing (Board) pursu-ant
to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. This audit was conducted under the authority
vested in the Auditor General by Arizona Revised Statutes
(A.R.S.) §41-2951 et seq.
Board Responsibilities
Since its inception in 1921, the Board of Nursing has been re-sponsible
for regulating registered nurses (RNs) through licen-sure.
In 1952, the Board’s responsibilities were expanded when
licensed practical nurses (LPNs) were added to the Board’s regu-latory
responsibilities. In 1990, as a result of federal requirements,
the Board received the responsibility for certifying nursing assis-tants
(CNAs). This responsibility for CNAs was expanded in
1995, when the Board received statutory authority to regulate
CNAs. Item 1 (see page 2) lists the primary licenses and certifi-cates
the Board is responsible for issuing. The Board offers addi-tional
credentials for RNs, including certification for advanced
practice nurses, such as nurse practioners and clinical nurse spe-cialists,
as well as prescribing privileges that allow advanced
practice nurses to prescribe and dispense drugs or medication to
patients.
The Board’s mission is:
“To protect the public health, safety, and welfare
through the safe and competent practice of nursing and
nursing assistants.”
Introduction and Background
2
OFFICE OF THE AUDITOR GENERAL
The Board accomplishes this mission by performing a variety of
functions, including:
n Issuing and renewing licenses and certificates to persons who
practice nursing or act as nursing assistants and possess the
required qualifications;
n Conducting investigations and hearings concerning unpro-fessional
conduct or other violations of the Nurse Practice
Act;1
n Disciplining violators; and
n Providing consumer information to the public.
1 The Nurse Practice Act consists of the Board’s statutes and rules and gov-erns
the licensure and regulation of RNs, LPNs, and CNAs.
Item 1: Licenses and Certificates
Issued by the Board
¾ Registered Nurse (RN): RNs are professional nurses who have
obtained an associate’s or bachelor’s degree in nursing or a di-ploma
from a professional nursing program. Typical duties in-clude
observing, assessing, and recording symptoms, reactions,
and progress; developing and managing nursing care plans;
administering medications; assisting physicians during treat-ments
or examinations; instructing patients in proper care; and
supervising LPNs and CNAs.
¾ Licensed Practical Nurse (LPN): LPNs must complete a one-year
practical nursing training program and provide care only
under the supervision of an RN or licensed physician. Typical
duties include taking vital signs, such as temperature and blood
pressure; giving injections; and observing, recording, and re-porting
a patient’s condition to his/her supervisor. However,
LPNs cannot provide an assessment of the patient’s condition.
¾ Certified Nursing Assistant (CNA): To become certified, nurs-ing
assistants must complete 120 hours of training. Typical du-ties
include assisting patients with eating, dressing, bathing, and
walking. A CNA may not perform any task requiring judgment
based on nursing knowledge, such as administering medica-tions.
Introduction and Background
3
OFFICE OF THE AUDITOR GENERAL
As of July 2001, the Board licenses approximately 47,300 RNs,
including 2,350 RNs certified as advanced practice nurses, and
9,320 LPNs and certifies approximately 18,600 CNAs.
Statutory Licensure
Requirements
The Board’s statutes contain the following general education and
examination requirements for licensure as an RN or LPN or certi-fication
as a CNA:
n Graduating from an approved professional nursing, practical
nursing, or nursing assistant program. These include schools
or colleges that award degrees in professional or practical
nursing and that are approved by the Board and/or are ac-credited
by a national nursing accrediting agency. This also
includes schools or nursing care facilities that issue certifi-cates
in nursing assistant training that are approved by the
Board and/or are accredited by a national accrediting
agency. Currently, there are 22 schools in Arizona offering
degrees in professional and/or practical nursing and ap-proximately
150 nursing assistant training programs.
n Passing an approved examination administered by a private
testing company, or possessing an unrestricted license or cer-tificate
from another state, district, or territory with similar
standards.
In addition to the general education and examination require-ments,
statute requires candidates for licensure or certification
who have been convicted of one or more felonies to have com-pleted
the sentences for all felony convictions and received abso-lute
discharge five or more years before they file an application
with the Board.
Complaint Resolution
The Board investigates and adjudicates complaints involving
violations of the Nurse Practice Act, such as potential unprofes-sional
conduct by nurses and CNAs. A.R.S. §32-1601 defines the
Introduction and Background
4
OFFICE OF THE AUDITOR GENERAL
actions that constitute unprofessional conduct for nurses and
CNAs, including such
things as any conduct or
practice that is or might be
harmful or dangerous to the
health of a patient or the
public. When Board staff
receive a complaint alleging
that a nurse or CNA vio-lated
a provision of the
Nurse Practice Act, they
open an investigation. In
addition, the Board investi-gates
criminal and discipli-nary
histories of current li-cense
or certificate holders and applicants. Specifically, the Board
conducts investigations when background checks reveal, or the
nurse or CNA discloses, the presence of criminal activity or dis-ciplinary
action taken against a nurse’s or CNA’s license or cer-tificate
in another state.
Prior to beginning an investigation, the Board’s executive direc-tor
or associate director reviews complaints and assigns them an
investigation priority. As seen in Item 2, a complaint can be as-signed
one of three different priority levels depending on the se-riousness
of the allegations, with priority 1 being the highest. An
investigation includes obtaining a response to the complaint
from the accused nurse or CNA; subpoenaing relevant records,
such as employment, medical, or motor vehicle records; and in-terviewing
the accused nurse or CNA, the complainant, and any
pertinent witnesses. After the investigation is completed, the
Board reviews the complaint and adjudicates it. At this time, the
named nurse or CNA has the opportunity to address the Board.
The Board votes to resolve each complaint using one of its statu-tory
nondisciplinary or disciplinary options. The Board’s nondis-ciplinary
options for nurses and CNAs are:
n Dismissing the complaint; or
n Issuing a Letter of Concern.
Item 2: Complaint
Priorities
Priority 1: Complaints that pose im-mediate
danger to public safety and
must be investigated immediately,
including chemical use while on duty
and all sexual allegations.
Priority 2: Complaints that are serious
but pose less of a threat than priority 1
complaints. Includes allegations of
abuse, negligence, and incompetence.
Priority 3: Complaints that pose little
to no threat of harm to public safety.
Investigating and adjudi-cating
complaints is a
major Board responsibil-ity.
Introduction and Background
5
OFFICE OF THE AUDITOR GENERAL
If the Board votes to impose discipline, its options for nurses are:
n Issuing a Decree of Censure;
n Imposing a term of probation, which can include require-ments
for mental, physical, or psychological examinations,
bodily fluids testing, or educational requirements;
n Imposing civil penalties; or
n Suspending or revoking the nurse’s license.
The Board’s disciplinary options for CNAs are:
n Imposing civil penalties; or
n Suspending or revoking the CNA’s certificate.
In addition, as authorized by statute, the Board operates a confi-dential,
nondisciplinary program for nurses with chemical de-pendencies,
known as the Chemically Addicted Nurses Diver-sion
Option (CANDO). If the Board receives a complaint against
a nurse indicating that the nurse is chemically dependent, the
nurse can voluntarily enter the CANDO program before an in-vestigation
is initiated. To participate in the CANDO program,
the nurse must enter into an agreement with the Board that con-tains
stipulations, such as participating in the program for at
least three years, completely abstaining from alcohol and all
other mind/mood-altering medications and controlled and/or
addictive substances, and entering a Board-acceptable chemical
dependency treatment program. While many nurses opt to par-ticipate
in CANDO as a result of a complaint against them, they
can also voluntarily enter the program even though no com-plaints
have been filed.
Organization and Staffing
The Board consists of nine governor-appointed members who
serve five-year terms. Five of the members must be registered
nurses, two members must be licensed practical nurses, and two
members must represent the public.
Introduction and Background
6
OFFICE OF THE AUDITOR GENERAL
In fiscal year 2001, the Board is authorized 53.8 full-time equiva-lent
(FTE) positions. This includes nine investigator FTEs re-cently
assigned to the Board to help it address its large number
of open investigations, seven of which are two-year temporary
positions (see Finding I, pages 11 through 18). Board staff also
includes an executive director, an associate director responsible
for operations, an associate director responsible for investiga-tions,
and several legal secretaries, licensing technicians, and
other support staff.
Budget
The Legislature establishes an expenditure limit on monies the
Board collects and deposits in the Board of Nursing Fund. This
fund contains revenues derived principally from the collection of
licensure application and renewal fees. The Board deposits 90
percent of its revenues into the fund and the remaining 10 per-cent
into the State’s General Fund.
In November 2000, the Board requested that the Legislature ap-propriate
additional monies from the Board’s fund to allow it to
hire additional investigators to help address its large number of
investigations.1 In response to this request, the Legislature ap-propriated
$772,700 from the Board’s fund over fiscal years 2001
and 2002. This is enough to hire nine investigator FTEs. Table 1
(see page 7) illustrates the Board’s actual revenues and expendi-tures
for fiscal years 1999 through 2001.
1 This request was made pursuant to a provision of the General Appropria-tion
Act, which allows 90/10 boards to request an additional $50,000 or 20
percent of the board’s current fiscal year appropriation when faced with
unanticipated costs. This allows boards to access monies from their funds
without having to request a supplemental appropriation during the regu-lar
legislative session.
The Board received addi-tional
money in fiscal year
2001 to hire more investi-gators.
Introduction and Background
7
OFFICE OF THE AUDITOR GENERAL
Table 1
State Board of Nursing
Statement of Revenues, Expenditures, and Changes in Fund Balance
Years Ended June 30, 1999, 2000, and 2001
(Unaudited)
1999 2000 2001
Revenues:
Licenses, fees, and permits $2,111,536 $2,322,432 $3,247,968 1
Intergovernmental 408,608 436,159 209,700
State General Fund appropriation 2 321,200
Fines and forfeits 147,782 120,653 130,908
Other 186,411 236,105 198,380
Total revenues 2,854,337 3,436,549 3,786,956
Expenditures:
Personal services 3 1,295,358 1,640,785 1,831,238
Employee-related 3 249,109 315,697 348,705
Professional and outside services 4 283,642 430,648 447,456
Travel, in-state 24,180 12,977 19,379
Travel, out-of-state 5,542 13,397 16,362
Other operating 303,138 335,154 421,092
Equipment 53,434 80,859 259,595
Total expenditures 2,214,403 2,829,517 3,343,827
Excess of revenues over expenditures 639,934 607,032 443,129
Other financial sources (uses):
Net operating transfers in (out) (4,712) (4,213) 98,731
Remittances to the State General Fund 5 (264,587) (274,395) (367,277)
Total other financing uses (269,299) (278,608) (268,546)
Excess of revenues expenditures and other
financing uses 370,635 328,424 174,583
Fund balance, beginning of year 1,933,297 2,303,932 2,632,356
Fund balance, end of year $2,303,932 $2,632,356 $2,806,939
1 Amount increased significantly from 2000 because the Board raised licensing fees when it extended licenses for registered
nurses and licensed practical nurses to three years.
2 The Board received a one-time State General Fund appropriation in 2000 to pay for fingerprinting certified nursing assis-tant
applicants. As of June 30, 2001, the Board’s unexpended $90,179 is included in the end of year fund balance.
3 Personal services and employee-related expenditures increased for nine new full-time equivalent (FTE) positions author-ized
by the Legislature in 2000 and another nine FTE positions in 2001.
4 Professional and outside services for 2000 and 2001 include expenditures approved by the Legislature to purchase various
automation services needed to link the Board’s database file to its Web site, store applications on microfilm, and imple-ment
a document scanning system.
5 As a 90/10 agency, the Board remits all of its administrative penalties and 10 percent of all other revenues to the State
General Fund.
Source: Auditor General staff analysis of the Arizona Financial Information System Revenues and Expenditures by Fund, Pro-gram,
Organization, and Object, Trial Balance by Fund, and Status of Expenditures and Appropriations reports for the years
ended June 30, 1999, 2000, and 2001.
Introduction and Background
8
OFFICE OF THE AUDITOR GENERAL
Audit Scope and
Methodology
Audit work focused on the Board’s investigation and adjudica-tion
processes, public information practices, and regulation of
CNAs. This performance audit and Sunset review includes find-ings
and recommendations as follows:
n The Board needs to improve the timeliness of its complaint
investigations (see Finding I, pages 11 through 18); and
n The Board needs to strengthen its public information policies
and practices (see Finding II, pages 19 through 23).
In addition, this report contains an Other Pertinent Information
section that provides information regarding the regulation of
CNAs in Arizona (see pages 25 through 29).
This audit used a variety of methods to study the issues ad-dressed
in this report, including the following:
n To assess the timeliness of the Board’s complaint investiga-tions,
auditors reviewed a random sample of 83 complaints
that were presented to the Board for adjudication during fis-cal
year 2000. This sample included: 1) 30 dismissed com-plaints
that met Board criteria for expedited adjudication and
shortened investigation time frames; 2) 23 complaints that re-sulted
in nondisciplinary Letters of Concern and also met
Board criteria for expedited adjudication and shortened in-vestigation
time frames; and 3) 30 complaints that proceeded
through the Board’s full investigative and adjudication proc-esses.
Auditors’ review of the latter group also assessed the
quality of the Board’s investigations and the appropriateness
of the Board’s adjudication practices.
n To determine whether the Board provides consumers with
accurate and complete information about nurses or CNAs,
including complaint histories, auditors posing as members of
the public made five calls to the Board requesting informa-tion
and compared the information provided to the Board’s
complaint records.
Introduction and Background
9
OFFICE OF THE AUDITOR GENERAL
n To compare Arizona’s regulation of CNAs to other states,
auditors reviewed the CNA regulatory structures of all 50
states as reported in the February 2001 National Council of State
Boards of Nursing Directory of Nurse Aide Registries. In addition,
auditors researched the Web sites of eight states to verify the
appropriate state agency regulating CNAs because the Direc-tory
was unclear.1 Further, auditors contacted ten states rep-resenting
the various regulatory structures to obtain further
information on those structures.2
This audit was conducted in accordance with government audit-ing
standards.
The Auditor General and staff express appreciation to members
of the Board of Nursing, the executive director, and staff for their
assistance throughout the audit.
1 The following eight state Web sites were researched to verify the appro-priate
state agency regulating CNAs: Delaware, Georgia, Illinois, Maine,
Michigan, New Mexico, Tennessee, and Texas.
2 The following 10 states were contacted because they were representative of
the various CNA regulatory structures used throughout the 50 states: Cali-fornia,
Florida, Indiana, Kentucky, Louisiana, Missouri, New Jersey, Ore-gon,
Virginia, and Washington.
10
OFFICE OF THE AUDITOR GENERAL
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11
OFFICE OF THE AUDITOR GENERAL
FINDING I THE BOARD SHOULD
IMPROVE THE TIMELINESS OF
ITS COMPLAINT INVESTIGATIONS
The Board of Nursing should take several steps to ensure that
complaints are resolved in a timely manner. Extremely slow
complaint investigations and a large number of open investiga-tions
decrease the Board’s ability to protect the public. Addi-tional
CNA regulatory responsibilities, inadequate tracking of
complaint investigation progress, and high turnover among its
investigative staff have affected the Board’s ability to conduct
complaint investigations in a timely manner. Changes, such as
developing internal investigation time frames and generating
management reports, can help improve investigation timeliness.
Slow Investigations
Decrease Board’s Public
Protection Efforts
The Board’s untimely complaint investigations decrease its abil-ity
to adequately protect the public from nurses and CNAs who
violate nurse practice laws. Specifically, the Board took over 360
days to investigate over half of the cases auditors reviewed,
while it currently has approximately 1,750 open investigations.
These untimely investigations diminish the Board’s public pro-tection
efforts.
Board’s investigation time frames are excessive—Auditors’ re-view
of 83 complaints presented to the Board in fiscal year 2000
for adjudication found that many took several hundred days to
complete.1 Of the 83 cases reviewed, the Board’s investigation
times ranged from 32 days to 1,938 days, with over half of these
1 The 83 investigations reviewed did not include investigations that arose as
a result of information disclosed on license/certificate applications or
background checks. When these investigations are combined with com-plaint
investigations, the Board reports that it takes an average of nine to
ten months to complete an investigation.
Board investigation time
frames ranged from 32 to
1,938 days.
Finding I
12
OFFICE OF THE AUDITOR GENERAL
investigations taking longer than 360 days and 23 complaints re-quiring
over 1,000 days to investi-gate.
Even the most critical com-plaints
often take too long to inves-tigate.
Auditors reviewed 4 com-plaints
labeled as priority 1, which
are deemed the most critical and
usually involve patient safety is-sues,
and found that 2 took over 270
days to investigate.
The Board also has a large number
of open investigations that have not been completed for several
years. As of August 2001, the Board had approximately 1,750
open investigations, of which over 36 percent were opened prior
to 2000.1 As illustrated in Item 3, 25 investigations initiated in
1996 and 122 investigations initiated in 1997 remained unre-solved
as of August 2001. In addition, the Board reports that it
typically receives hundreds of new cases for investigation each
year, including complaints and license or certificate applicant
background investigations. In fact, during fiscal year 2000, the
Board reports opening over 2,200 new investigations.
Even when complaints are opened for investigation, they often
sit for long periods of time during the investigation. Specifically,
for the cases reviewed, auditors found significant time gaps
where no investigative work was performed. For example:
¾ A nurse employed by a nursing home accused of failing to
report patient abuse was under investigation for over three
years. The Board received the complaint in July 1997 and sent
a letter to inform the nurse of the investigation one month
later. However, no further investigative work was conducted
until the Board contacted the nurse in January 2000. Further,
the Board did not subpoena pertinent records until February
2000. The case was finally resolved in September 2000, when
the Board issued a nondisciplinary Letter of Concern.
1 This includes both complaint investigations and investigations that arose
as a result of information disclosed on license/certificate applications or
background checks.
Item 3: Open
Investigations
As of August 2001
By Year of Receipt
1996: 25 Cases
1997: 122 Cases
1998: 220 Cases
1999: 272 Cases
2000: 556 Cases
2001: 560 Cases
Board has approximately
1,750 open investigation
cases as of August 2001.
Finding I
13
OFFICE OF THE AUDITOR GENERAL
n A nurse was under investigation for over four years as a re-sult
of an anonymous complaint alleging a substance abuse
problem. The Board received the complaint in August 1995
and spoke with the nurse in November 1995 to inform her of
the option of entering the Board’s special program for chemi-cally
addicted nurses. However, no records were subpoe-naed
until February 1996, and it was not until over two-and-a-
half years later, in September 1998, that any further investi-gative
work was conducted. In March 1999, the complaint
was reassigned to another investigator who finally com-pleted
the investigation and brought the complaint to the
Board for adjudication in October of 1999. The Board voted to
dismiss the complaint.
Successfully resolving complaints can be made more difficult by
the fact that information needed to support allegations may be-come
harder to obtain as time passes. Witnesses, as well as com-plainants
and accused nurses and CNAs, forget details of the in-cidents,
or move and do not provide updated contact informa-tion.
For example, the Board did not conduct any investigative
work on one case for almost four years. Once the investigator
began working on the case, she had difficulty contacting the ac-cused
nurse. Eventually, the Board learned that the nurse had
died.
Untimely investigations lead to inadequate public protection—
Because investigations take so long, certain nurses or CNAs with
problems could continue to practice unchecked. While nurses
and CNAs are under investigation, their licenses are not re-stricted.
As a result, these individuals can continue to practice for
long periods without receiving appropriate disciplinary action
and without addressing the problems identified. In addition, the
public is not informed of the Board’s concerns with these nurses
or CNAs and is open to possible substandard care for long peri-ods.
For example:
n In October 1995, the Board received a complaint that a psy-chiatric
facility nurse sent a 17-year-old inmate with a history
of recent suicide attempts back to his cell, without calling a
psychiatrist and without instituting proper precautions. The
inmate committed suicide within an hour of speaking with
the nurse. The complaint also alleged that the nurse had al-
Finding I
14
OFFICE OF THE AUDITOR GENERAL
tered the inmate’s medical chart. Despite the seriousness of
these allegations, the Board took nearly four years to com-plete
its investigation. In September 1999, the Board voted to
place the nurse on probation for 36 months with stipulations
that she could not work with children or adolescents and
could not work in any psychiatric settings. However, during
the course of the investigation, the nurse continued to work
unrestricted for at least four different employers.
n In June 1996, the Board received a complaint that a nurse was
administering medication without a doctor’s orders and was
disposing of unused narcotics without proper witnesses or
documentation, as required by policy. During a lag in the in-vestigation,
a second complaint was received in March 1997
alleging that this nurse again failed to properly account for
two doses of narcotics and that four doses of an anti-anxiety
medication meant for her patients were missing during her
shift. Additionally, during the investigation period, the nurse
disclosed a shoplifting conviction on her license renewal ap-plication.
Despite these two complaints, this case was not
heard by the Board until October 1999, when it decided to
place the nurse on an 18-month probation that required
counseling and direct supervision.
Three Factors Affect Board’s
Ability to Investigate Complaints
In a Timely Manner
Three factors affect the Board’s ability to conduct investigations
in a timely manner. First, an increase in CNA regulatory respon-sibilities
has resulted in an increase in the number of investiga-tions
the Board must conduct each year. In addition, Board staff
do not track the progress of investigations to ensure they are
completed in a timely manner. Finally, high turnover among in-vestigative
staff in fiscal years 1999 and 2000 further hampered
the Board’s ability to conduct timely investigations.
Increased CNA regulatory responsibilities affect Board’s inves-tigation
timeliness—Changes in the Board’s CNA regulatory
responsibilities have contributed to its inability to investigate
complaints in a timely manner. Specifically, in 1995, the Board
Finding I
15
OFFICE OF THE AUDITOR GENERAL
became responsible for investigating complaints alleging viola-tions
of the Nurse Practice Act by CNAs. Further, in January
1999, the Board was given responsibility for conducting back-ground
checks on CNAs, as well as RNs and LPNs, and investi-gating
issues arising from these checks, such as undisclosed
criminal convictions. These expanded CNA responsibilities in-creased
the number of investigations the Board conducts each
year. In fact, the Board reports that the number of investigations
it must conduct has tripled since 1995. Prior to the added CNA
responsibilities, the Board reports that it received an average of
47 complaints for investigation each month. However, for fiscal
year 2000, the Board reports that it received an average of 188
investigations arising as a result of complaints or licensing back-ground
checks each month. In addition, of the approximately
1,750 investigations open as of August 2001, over 1,200 are re-lated
to CNAs. (See Other Pertinent Information, pages 25
through 29, for more information on the Board’s regulation of
CNAs.)
Board staff do not monitor investigation progress—Board staff
do not currently monitor the progress of its investigations to en-sure
that they are timely. Specifically, while the Board has spe-cific
procedures that investigators must follow when conducting
investigations, there are no time frames attached. As a result, as
seen in some of the previous examples, investigators may open
an investigation by sending initial letters to the complainant and
respondent, but then not work an investigation for months or
even years because they receive other complaints that may be of
higher priority or are having problems obtaining documents or
locating respondents or witnesses. In addition, while the Board
has a computer system that is designed to capture data on com-plaints
and investigations, it does not currently provide man-agement
with accurate and complete information on the status of
investigation. As result, most investigators do not enter data into
the system. Aware of its computer problems, the Board re-quested
and has received additional monies in fiscal year 2002 to
update its computer system.
Investigative staff turnover hampered timeliness—Finally, sig-nificant
turnover among investigative staff has affected the
Board’s ability to investigate complaints in a timely manner. In
fiscal year 1999, 7 of the Board’s 19 investigators left their posi-
Board’s increased CNA
responsibilities have in-creased
its investigations
workload.
Finding I
16
OFFICE OF THE AUDITOR GENERAL
tions. Further, while the Board received an additional 3 investi-gator
positions in fiscal year 2000, giving it a total of 22 investiga-tors,
4 of these positions were vacated during that fiscal year. Ac-cording
to Board officials, these vacancies create skill losses that
often take 9 to 12 months of training to replace.
Changes Needed to Improve
Investigation Timeliness and Reduce
Number of Open Investigations
The Board should take several steps to improve its investigation
timeliness and reduce the number of open complaint investiga-tions.
Specifically, while the Board has completed an important
step toward reducing the number of open complaint investiga-tions
by requesting and receiving additional investigators, it
should monitor the progress of its investigators to ensure that its
complaint investigation goals are met. In addition, the Board
should develop internal time frames for each stage of the investi-gative
process and take steps to ensure that its computer system
can generate reports to help it better oversee and monitor its
complaint investigations. Finally, the Board should consider op-tions
for ensuring that it can adjudicate the additional complaints
in a timely manner.
Monitor progress of additional investigation resources—The
Board should monitor its progress in using the additional inves-tigative
resources it obtained to help it address its numerous
open complaint investigations. In fiscal year 2001, the Board re-quested
and the Legislature granted additional funding for more
investigators to assist the Board in completing its large number
of open investigation cases. Specifically, the Legislature ap-proved
$271,700 for fiscal year 2001 and $501,000 for fiscal year
2002 from the Board’s fund to pay for nine additional investiga-tor
FTEs. However, seven of these additional FTEs are only tem-porary,
two-year positions. To make the best use of these tempo-rary
staff, the Board has implemented an informal plan, includ-ing
performance goals, to help it reduce the number of open
complaint investigations. This plan includes using these staff to
assist the Board’s existing investigative staff in resolving current
investigations. To ensure that this plan is effectively carried out,
and to eliminate as many open complaint cases as possible be-
Board received additional
monies for seven tempo-rary
and two permanent
investigator positions.
Finding I
17
OFFICE OF THE AUDITOR GENERAL
fore June 30, 2002, when it will lose the seven temporary investi-gators,
the Board should monitor its progress in meeting the per-formance
goal of having each new investigator complete at least
ten investigations each month.
Develop internal time frames for each stage of the investigation
process—The Board should establish internal time frames for
each phase of its investigation process to help ensure timely in-vestigations.
Creating deadlines for different phases of the proc-ess
could assist the Board in ensuring that cases are not unat-tended
for extended periods. When developing these internal
time frames, the Board should ensure that the number of days
from complaint receipt to adjudication is no longer than 180
days. One hundred eighty days is a reasonable amount of time to
investigate and adjudicate complaints based on auditors’ review
of complaint investigation and adjudication time frames used by
other health regulatory boards.
Until the Board eliminates the numerous complaint investiga-tions
currently open, it may be difficult for Board staff to make
certain all investigations meet implemented time frames. How-ever,
the Board needs to establish time frames and, at a mini-mum,
make certain that all priority 1 cases meet them.
Ensure data management system provides for investigation
monitoring—The Board should ensure that changes to its com-puter
software are made and include the capability to generate
accurate reports that management can use to monitor the status
of open investigations. Once these computer system changes are
completed, the Board should generate monthly management re-ports
to help it track investigation timeliness by ensuring that the
internal time frames for each stage of the investigative process
are met.
Consider options for adjudicating complaints in a timely man-ner—
Because the nine additional investigators will likely in-crease
the number of cases requiring adjudication, the Board
may need to adopt alternative complaint resolution methods to
ensure that it can address the increased workload. Currently, the
Board meets every four to six weeks for two full days and is able
to resolve all complaints that have completed investigations.
During March, April, and May 2001, the Board addressed an av-
Board should develop
time frames to help
ensure it can complete
investigations in a
timely manner.
Finding I
18
OFFICE OF THE AUDITOR GENERAL
erage of 160 investigative cases and other adjudication matters
during each meeting. To help it address complaints in a timely
manner, the Board has implemented time-saving measures, such
as mass dismissal of complaints that it determines to be without
merit. However, now that the Board’s new investigators are ex-pected
to complete at least 10 investigations each to bring to the
Board for adjudication at each Board meeting, the number of
cases the Board will need to address could increase by as many
as 90 cases each month. In fact, during its June 2001 meeting, the
Board was presented with 357 cases, including investigations
and other items requiring Board action, but had to postpone tak-ing
action on 58 cases because it did not have sufficient time to
address them. Therefore, if the Board determines it cannot re-solve
all investigated complaints in a timely manner, it should
consider additional adjudication options. For example, the Board
could divide into two panels or subcommittees to review com-plaints
or meet more frequently to address the increased number
of complaints that will be brought before it.
Recommendations
1. The Board should monitor the progress made by its addi-tional
investigator FTEs toward meeting performance goals.
2. The Board should establish internal time frames for each
phase of its investigations, with the total number of days
from complaint receipt through adjudication being no longer
than 180 days.
3. While working to clear its open investigations, the Board
should ensure that, at a minimum, all priority 1 investiga-tions
adhere to the established investigation process time
frames.
4. The Board should generate management reports that track
the status of open complaint investigations.
5. The Board should consider options, such as dividing into two
panels or subcommittees to review complaints or meeting
more frequently, in order to adjudicate in a timely manner
the increased number of complaints likely to be brought be-fore
it.
19
OFFICE OF THE AUDITOR GENERAL
FINDING II BOARD PRACTICES
RESTRICT ACCESS TO
PUBLIC INFORMATION
The public does not have appropriate access to information re-garding
nurses and CNAs. Auditor test phone calls found that
the Board was inconsistent in its provision of public information
about licensees and certificate holders because its policies and
procedures are not clear as to how staff should respond to public
information requests. In addition, certain Board practices, such as
asking consumers for their name and phone number, as well as
the manner in which phone calls are routed, impedes consum-ers’
access to public information. Therefore, the Board should
strengthen its policies to clarify what information can be pro-vided
to consumers and should eliminate its restrictive practices.
Providing Public Information
Is an Important Part of a Regulatory
Board’s Responsibilities
One important part of a regulatory board’s responsibilities is
providing information that allows the public to make informed
decisions about utilizing the services of licensees or certificate
holders regulated by the board. For example, by informing the
public of the disciplinary actions taken against licensees or cer-tificate
holders, boards assist consumers in selecting competent
and ethical professionals. Public records laws were developed in
part to help ensure that boards make this necessary information
available.
Board Needs to Provide More
Complete Public Information
The Board’s inconsistent practices impede consumer access to
public information. Specifically, auditor test calls to the Board
Finding II
20
OFFICE OF THE AUDITOR GENERAL
resulted in varied responses, with some auditors being able to
obtain appropriate information about nurses and CNAs while
others were given incomplete information. To ensure that con-sumers
consistently have appropriate access to public informa-tion
about nurses and CNAs, the Board should strengthen its
public information policies and practices.
Auditor tests found the Board’s public information practices
varied—Five auditors posing as members of the public phoned
the Board and requested information on five different licen-sees/
certificate holders. While two of the auditors’ requests for
information were appropriately handled by the Board, the Board
did not fully disclose all available public information to the other
three auditors. In one case, the Board refused to provide infor-mation
on the general nature of a pending investigation. In an-other
case, the Board failed to inform the auditor that a nurse
with a letter of concern was the subject of a dismissed complaint.
Finally, another auditor was unable to obtain any complaint or
disciplinary information regarding a nurse, despite phone calls
and a visit to the Board’s offices. Specifically, one auditor was
told that complaint and disciplinary information could not be
provided over the phone and an appointment must be made to
view the nurse’s records at the Board’s offices. After unsuccess-fully
attempting for two weeks to make an appointment to view
the records, the auditor went to the Board’s offices. The auditor
was first informed that the Board would not release the informa-tion
she was requesting and was then told she could not see the
file; rather, she could only get copies of the nurse’s file at a cost
of $.50 per page.
Strengthen public information policies and practices—To help
ensure consumers have access to all public information, the
Board should strengthen its policies to detail the information that
will be made available to the public and then train staff on how
to properly respond to public information requests. The Board’s
current public information policies and procedures are unclear
regarding how public information requests on dismissed or
closed complaints and disciplinary histories should be handled.
Therefore, the Board should strengthen its policies and ensure
information is provided on nurses or CNAs with dismissed or
The Board’s response to
calls requesting public
information varied.
Board should clearly de-fine
what information can
be made public.
Finding II
21
OFFICE OF THE AUDITOR GENERAL
closed complaints, including the number and nature of dis-missed
complaints and the nature and resolution of closed com-plaints.
Other state agencies and boards have developed written
policies to make this information available by phone. For in-stance,
the Board of Psychologist Examiners has policies requir-ing
staff to provide the public with information over the tele-phone
regarding the number and nature of both dismissed and
pending complaints, and the resolution of closed complaints.
Board Should Provide Easier
Access to Public Information
The Board should also take steps to make public information
more accessible to consumers. Currently, the Board’s policy of
asking consumers for personal information, as well as the man-ner
in which the Board routes phone calls, hinders the public’s
access to information about nurses and CNAs. The Board should
eliminate these restrictive practices to provide consumers with
easier access to public information.
Certain Board practices impede consumer access to public in-formation—
Currently, the Board has two particular practices
that impede consumers’ access to public information on nurses
and CNAs. Specifically:
n Board staff question consumers—According to policy,
Board employees are required to obtain descriptive informa-tion
about all callers requesting public information on licen-sees
or certificate holders. Specifically, the policy states that
the caller’s name and information, such as the phone number
and reason for the public information request, should be re-corded
by the Board employee handling the call. While the
Board has implemented this policy in order to protect nurses’
and CNAs’ safety because home addresses are considered
public information when business addresses are not pro-vided,
it could serve to discourage public requests for
information. Auditor test calls confirmed this practice when
four of the five auditors were asked for the reasons they were
requesting public information.
Finding II
22
OFFICE OF THE AUDITOR GENERAL
The Board should eliminate its policy requiring that staff ask
consumers to provide their names and other descriptive in-formation.
To address safety concerns, the Board should en-sure
that nurses and CNAs are informed as to what informa-tion
is considered public, including the fact that home ad-dresses
are considered public information when business
addresses are not provided.
n Board’s phone system is difficult to use—The Board’s
phone system further impedes consumers’ access to public
information. While the Board uses an automated phone sys-tem
for routing phone calls, it is difficult to navigate, making
it hard for callers to speak with Board staff. Specifically, the
automated phone system does not contain an option clearly
intended and labeled for the general public to inquire about a
nurse’s or CNA’s record with the Board. Auditors had to
place several calls to the Board before they were able to speak
to a Board employee. For the most part, auditors’ calls were
routed to a general voicemail box where they were instructed
to leave a message and await a return call. Although one
auditor did leave a message, she never received a response.
This same auditor then had to make four separate calls to the
Board on the same day to speak with a Board employee.
To ensure that consumers have proper access to Board staff
who can handle their information requests, the Board should
consider adding an option to its automated phone system to
route the caller to a designated Board employee or adding
additional phone lines to allow for proper routing of calls. In
addition, the Board could consider establishing a customer
service unit to handle the public’s calls, including public in-formation
requests.
Board’s automated phone
system impedes access to
public information be-cause
it is difficult to
navigate.
Finding II
23
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Board should strengthen its public information policies
to guide staff in providing public information to consumers
over the telephone and in person, including providing the
number and nature of closed, dismissed, and pending com-plaints
and disciplinary actions.
2. The Board should train staff on how to appropriately provide
public information to consumers by phone and in person.
3. The Board should eliminate its restrictive policies requiring
staff to obtain the names and other descriptive information of
consumers requesting public information.
4. The Board should ensure that nurses and CNAs know what
information is considered public, including the fact that
home addresses are considered public information when
business addresses are not provided.
5. The Board should develop and implement a plan to route
public calls, such as adding a public information option to its
automated phone system, adding additional phone lines, or
establishing a customer service unit to handle consumer
information requests.
24
OFFICE OF THE AUDITOR GENERAL
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25
OFFICE OF THE AUDITOR GENERAL
OTHER PERTINENT INFORMATION
During the audit and in response to legislative inquiries, other
pertinent information was gathered regarding the appropriate-ness
of the Board of Nursing regulating certified nursing assis-tants.
Regulating Certified
Nursing Assistants
In response to federal requirements, the State began regulating
certified nursing assistants (CNAs) in 1990. While the federal
government established minimum standards for regulating
nursing assistants, Arizona expanded its CNA regulation re-quirements.
Regulation by the Board of Nursing is one of three
primary CNA regulatory structures employed by the 50 states.
Although the Board has struggled with this responsibility in the
past, its years of experience in certifying nursing assistants and
current resource levels should enable it to more efficiently and
effectively manage this responsibility in the future.
Since 1990, the Board of Nursing has been responsible for certify-ing
nursing assistants in the
State. As illustrated in Item 4,
nursing assistants provide a
wide variety of personal care
services through daily con-tact
with patients under
medical care and long-term
care facility residents. The
Board approves training pro-grams,
maintains a register of
CNAs, conducts background
checks on certification candi-dates,
and investigates com-plaints
against CNAs.
Item 4: Nursing
Assistants’ Duties
Nursing assistants provide assis-tance
with personal care such as:
n Bathing
n Dressing
n Walking
n Meal Preparation
n Feeding
These nursing-related services are
provided to patients in facilities and
to individuals in their own homes.
The Board has been re-sponsible
for certifying
nursing assistants since
1990.
Other Pertinent Information
26
OFFICE OF THE AUDITOR GENERAL
During fiscal year 2000, the Board reports receiving 3,963 appli-cations
for certification and over 1,000 complaints against CNAs.
Further, during that same year, the Board adjudicated 323 cases
that resulted in 111 disciplinary actions against CNAs. As of July
2001, there are approximately 18,600 CNAs listed in the register.
Federal and state requirements for CNA regulation—The regula-tion
of nursing assistants resulted from the federal government’s
1987 Omnibus Reconciliation Act (Act). Through this Act, the
federal government intended to protect individuals in nursing
homes and other federally funded long-term care settings from
improperly trained nursing assistants. In addition to requiring
states to certify nursing assistants working in Medicare-certified
long-term care facilities, the Act specified several minimum certi-fication
requirements.1 Specifically, the Act requires that 1) nurs-ing
assistants working in federally funded long-term care facili-ties
receive a minimum of 75 hours of standardized education; 2)
states maintain a registry of nursing assistants who have ob-tained
this training; and 3) the states investigate complaints of
abuse, neglect, or misappropriation of nursing home residents’
property. To help offset the costs of regulating CNAs, the Act
provides federal monies to the states. In fiscal year 2001, the
Board received approximately $365,000 from the federal gov-ernment
to regulate CNAs. However, the Act does not permit
states to charge a fee to nursing assistants in order to become cer-tified.
Arizona has established certification and regulatory require-ments
for nursing assistants that are more strict than those re-quired
by the federal government. Specifically, Arizona nursing
assistants must obtain at least 120 hours of standardized educa-tion
in order to qualify for certification. In addition, the State has
the authority to investigate and take disciplinary action against
certified nursing assistants who violate any provisions of Ari-zona’s
Nurse Practice Act. Finally, Arizona nursing assistants
seeking certification must submit to a criminal background
check, and the Board must deny certification to individuals with
1 Medicare-certified long-term care facilities include nursing homes, home
health agencies, and hospice agencies. The federal government mandates
that these facilities utilize CNAs.
A federal act requires all
states to certify nursing as-sistants
working in federally
funded long-term care set-tings.
Arizona’s nursing assis-tant
certification and
regulatory requirements
are more strict than the
federal minimum re-quirements.
Other Pertinent Information
27
OFFICE OF THE AUDITOR GENERAL
felony convictions who have not received an absolute discharge
from the convictions five or more years prior to applying for cer-tification.
Nursing boards one of three primary CNA regulatory struc-tures—
Auditors’ review of CNA regulation in each of the 50
states found that it is not unusual for CNAs to be regulated
through boards of nursing, health facility regulatory agencies, or
occupational licensing and regulatory agencies. Through this re-view,
the following three predominant regulatory structures
were identified:
n Boards of Nursing—In addition to Arizona, 13 other states
regulate CNAs through boards of nursing. While some of
these boards are responsible for maintaining only their state’s
CNA registry, many others, such as Arizona’s and Oregon’s
Board of Nursing, are responsible for certifying applicants,
investigating complaints, and approving training programs.
A benefit of regulating CNAs through boards of nursing is
that nurses and CNAs typically work together closely. Fur-ther,
boards of nursing already have an established system
for licensing and regulating similar professionals. Addition-ally,
the career track for CNAs leads some to become LPNs
or RNs and having them regulated by the same board makes
the licensing transition easier.
n Health Facility Regulatory Agencies—Twenty-nine states
regulate CNAs through agencies that also regulate health fa-cilities,
including long-term care facilities. For example, Indi-ana
regulates CNAs through its Department of Health, Divi-sion
of Long-Term Care. An advantage of regulating CNAs
through this model is that the facilities these agencies regu-late
typically employ CNAs. Therefore, these agencies have
experience in regulating the settings CNAs work in and have
knowledge of CNA duties and practices. In addition, these
agencies typically have extensive experience with federal
programs and contracts.
n Occupational Licensing and Regulatory Agencies—
Finally, five states regulate CNAs along with all other regu-lated
occupations or all other medical occupations. For ex-ample,
Alaska regulates CNAs through its Division of Occu-
Arizona is 1 of 14 states
that regulate CNAs
through boards of nurs-ing.
Other Pertinent Information
28
OFFICE OF THE AUDITOR GENERAL
pational Licensing, which also regulates occupations ranging
from acupuncturists to public accountants.
Board improving its ability to effectively regulate CNAs—While
Arizona’s Board of Nursing initially struggled with the responsi-bility
of regulating CNAs, it has received additional resources
that should allow it to more effectively manage the program.
When Arizona expanded its nursing assistant certification and
regulation requirements, the Board reports that its workload ex-panded
greatly and it did not have sufficient resources to prop-erly
address this increase. Specifically, in 1995, the Board re-ceived
authority to investigate complaints alleging violations of
the Nurse Practice Act. In addition, in 1998, the Board was given
responsibility for conducting background checks on CNAs and
investigating issues arising from these checks, such as undis-closed
criminal convictions. As a result of these expanded duties
in addition to other factors, the Board was unable to conduct
timely investigations of complaints against CNAs as well as
nurses (see Finding I, pages 11 through 18). Further, the Board’s
costs to certify and regulate CNAs were higher than the federal
monies it was receiving for performing that function, and the
Board did not receive increased revenues to correspond to the
increase in its regulatory responsibilities.
However, the Board has addressed some of its CNA regulation
challenges which, according to a Board official, should enable it
to better manage its CNA responsibilities within a year. Specifi-cally:
n Board received additional investigation resources—In
fiscal year 2001, the Board requested and the Legislature ap-proved
additional funding from the Board of Nursing Fund
for the Board to hire additional investigators to help elimi-nate
its large number of investigations. The Board now has
nine investigators who specialize in CNA-related investiga-tions,
although four are temporary positions that will termi-nate
in June 2002. In contrast, the Board had only one investi-gator
specializing in CNA cases prior to 1997.
n Board received additional monies—The Board has also
received additional monies to help offset its CNA regulatory
costs. In 1997, the Board added a $40 fee for an optional card
The Board has received
additional resources to
help it better manage its
CNA responsibilities.
Other Pertinent Information
29
OFFICE OF THE AUDITOR GENERAL
that CNAs can purchase to carry as proof of current certifica-tion.
Other nonappropriated monies, including these fees,
provide over $341,000 of the Board’s approximately $1.1 mil-lion
in CNA-related funding for fiscal year 2000. Further, the
Board received a $320,000 General Fund appropriation dur-ing
fiscal year 2000 to finance fingerprinting charges for re-quired
background checks. The Board will also receive
$132,000 in General Fund appropriations during both fiscal
years 2002 and 2003 for CNA fingerprinting.
30
OFFICE OF THE AUDITOR GENERAL
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31
OFFICE OF THE AUDITOR GENERAL
SUNSET FACTORS
In accordance with A.R.S. §41-2954, the Legislature should con-sider
the following 12 factors in determining whether the Ari-zona
State Board of Nursing (Board) should be continued or
terminated.
1. The objective and purpose of establishing the Board.
The Board was established in 1921 and its mission is to
protect the public’s health and welfare by overseeing and
ensuring the safe practice of nurses and nursing assis-tants.
To accomplish this mission, the Board established
goals addressing educational standards, the licensing and
regulation of nurses and nursing assistants, the approval
of nursing and nursing assistant programs, and the pro-vision
of a nondisciplinary program for chemically de-pendent
nurses.
In support of the Board’s mission and goals, the following
essential functions are carried out:
n Licensing—The Board licenses and certifies ap-proximately
75,000 individuals, including registered
nurses, licensed practical nurses, and certified nursing
assistants. In addition, the Board approves and over-sees
nursing and nursing assistant training programs.
n Investigation—The Board has the authority to inves-tigate
complaints against nurses and CNAs from the
public and on its own initiative. The Board also con-ducts
background checks on new applicants for licen-sure
or certification.
n Adjudication—The Board conducts hearings to re-solve
violations of the Nurse Practice Act by nurses
and CNAs.
Sunset Factors
32
OFFICE OF THE AUDITOR GENERAL
n Public Information—The Board provides informa-tion
to the public on nurses and CNAs.
2. The effectiveness with which the Board has met its
objective and purpose and the efficiency with which
it has operated.
The Board performs many of its responsibilities efficiently
and effectively, but could improve its performance in
other areas. Specifically, the Board issues licenses and cer-tificates
in a timely manner to qualified candidates. In
addition, the Board actively monitors Nurse Practice Act
violators to ensure they are fulfilling all stipulations of
their disciplinary agreements. The Board also operates a
program to assist chemically addicted nurses to facilitate
their rehabilitation and recovery. Further, auditors’ re-view
of 30 complaint investigations presented to the
Board for adjudication in fiscal year 2000 found that the
Board took appropriate disciplinary action when viola-tions
of the Nurse Practice Act were substantiated, and is-sued
Letters of Concern when violations were not sub-stantiated
but the Board had concerns about a nurse’s
conduct.
However, the Board needs to improve its efficiency and
effectiveness by investigating complaints in a timely
manner. Specifically, the audit found that factors, such as
an increase in workload, have hampered the Board’s abil-ity
to investigate complaints in a timely manner. To im-prove
its investigation timeliness, the Board should de-velop
time frames for each stage of its investigation proc-ess
and generate management reports on the status of
open investigations. Further, the Board should monitor
its plan for eliminating the large number of open investi-gations
using recently acquired additional investigator
positions (see Finding I, pages 11 through 18).
Sunset Factors
33
OFFICE OF THE AUDITOR GENERAL
3. The extent to which the Board has operated within
the public interest.
The Board has operated in the public interest in some ar-eas,
but can improve in others. Specifically, the Board ap-propriately
allows complainants to participate in all as-pects
of the complaint adjudication process. The Board
also publishes quarterly newsletters, which provide in-formation
on the Board’s most recent disciplinary actions
against nurses and CNAs as well as information on perti-nent
Board issues. This information is also available on
the Board’s Web site. Additionally, the Board sets aside
time at its meetings to address questions from the public,
including visiting nursing students.
However, the Board’s public information policies and
practices should be strengthened to ensure that consum-ers
have appropriate access to public information on
nurses and CNAs. Specifically, the Board’s policy is un-clear
as to how public information requests on dismissed
or closed complaints and disciplinary histories should be
handled. Therefore, the Board should strengthen its poli-cies
to outline what records and information should be
provided in response to public information requests on
nurses or CNAs with dismissed, pending, or closed com-plaints,
including the number and nature of dismissed
complaints and the resolution of closed complaints. Fur-ther,
the Board should eliminate its policy requiring that
staff ask consumers to provide their names and other de-scriptive
information when requesting public information
and simplify telephone access to Board staff who can
handle public information requests (see Finding II, pages
19 through 23).
4. The extent to which rules adopted by the Board are
consistent with the legislative mandate.
The Governor’s Regulatory Review Council (GRRC) ana-lyzed
the Board’s five-year rule review report in August
1997 and determined that the Board had adopted most of
the rules required by statute. However, GRRC found that
Sunset Factors
34
OFFICE OF THE AUDITOR GENERAL
18 of the Board’s rules were inconsistent with statute, in-cluding
the Board’s rules addressing licensing time
frames. The Board has since amended its rules regarding
licensure and certification time frames and licensure re-quirements.
However, changes to rules regarding train-ing
program approval and regulation have not yet been
made. The Board’s rules are due for review again in Au-gust
2001.
5. The extent to which the Board has encouraged input
from the public before adopting its rules, and the e x-tent
to which it has informed the public as to its ac-tions
and their expected impact on the public.
According to the Board, it has encouraged public input in
drafting its proposed rules. For example, the Board seeks
input from stakeholder groups such as the Arizona
Nurses Association. The Board also posts its hearing
agendas, which include time that has been set aside for
public input on rules, on its Web site and publishes no-tices
regarding proposed rule changes in its newsletter.
Further, the Board sends letters regarding proposed rule
changes to various stakeholders, such as nursing execu-tives,
who may be interested in the proposed changes.
Additionally, the Board has complied with the State’s
open meeting laws by posting public meeting notices at
least 24 hours in advance at the required location, making
agendas available to the public, maintaining meeting
minutes, and having the required statement of where
meeting notices will be posted on file with the Secretary
of State.
6. The extent to which the Board has been able to in-vestigate
and resolve complaints that are within its
jurisdiction.
The Board has sufficient statutory authority and discipli-nary
options to investigate and adjudicate complaints.
However, the Board is unable to investigate complaints in
a timely manner because of its increased workload dur-
Sunset Factors
35
OFFICE OF THE AUDITOR GENERAL
ing the past several years due to its expanded CNA regu-latory
duties, inadequate monitoring of complaint inves-tigation
progress, and the high turnover of investigative
staff that it experienced in 1999 and 2000. Specifically, a
review of 83 complaint investigations found that
investigation time frames ranged from 32 days to 1,938
days, with over half the cases taking at least 360 days to
investigate. While the Board has added investigative staff
to help address the large number of open complaints, it
should also establish investigation process time frames
and generate management reports that would enable
greater oversight of open investigations (see Finding I,
pages 11 through 18).
7. The extent to which the Attorney General or any other
applicable agency of state government has the au-thority
to prosecute actions under the enabling legis-lation.
A.R.S. §41-192 authorizes the Attorney General’s Office to
prosecute actions and represent the Board. Four assistant
attorneys general currently represent the Board.
8. The extent to which the Board has addressed defi-ciencies
in its enabling statutes which prevent it from
fulfilling its statutory mandate.
Numerous changes have been made to the Board’s stat-utes
in recent years, some of which have enhanced the
Board’s ability to fulfill its statutory mandate. For exam-ple:
n Laws 2001, Chapter 101 enacted a nurse licensure
compact, allowing RNs and LPNs licensed in other
compact states to practice in Arizona without obtain-ing
an Arizona license, beginning in July 2002.
n Laws 1999, Chapters 221 and 229 gave the Board au-thority
to impose civil penalties on CNAs and sus-pend
their certificates. Additionally, legislation passed
Sunset Factors
36
OFFICE OF THE AUDITOR GENERAL
changing the two-year renewal of RN/LPN licenses
to a four-year renewal period.
n Laws 1998, Chapter 84 gave the Board the authority to
require fingerprints and criminal histories of all nurse
licensure applicants. Further, the general require-ments
for licensure or certification were increased by
requiring the Board to deny licensure or certification
to individuals with felony convictions who have not
received an absolute discharge from the conviction
five or more years prior to applying for licensure or
certification.
n Laws 1997, Chapter 140 gave the Board the authority
to issue nondisciplinary Letters of Concern to CNAs.
For the 2002 legislative session, the Board plans to request
changes to the Nurse Practice Act. For example, because
of the enactment of a nurse licensure compact in 2001, the
Board would like to make changes to the Nurse Practice
Act to align it with the compact’s language.
9. The extent to which changes are necessary in the
laws of the Board to adequately comply with the fac-tors
listed in the Sunset law.
Based on audit work, no legislative changes are recom-mended.
10. The extent to which termination of the Board would
significantly harm the public health, safety, or wel-fare.
Terminating the Board would harm the public’s health,
safety, and welfare because the Board is responsible for li-censing,
investigating, and adjudicating complaints
against RNs, LPNs, and CNAs. Without the Board’s regu-latory
activities to ensure educational and competency
standards, the public could be subject to untrained and
unskilled nursing practices. Currently, all 50 states regu-
Sunset Factors
37
OFFICE OF THE AUDITOR GENERAL
late the nursing practice and federal regulations mandate
that the State maintain a register of CNAs.
11. The extent to which the level of regulation exercised
by the Board is appropriate and whether less or more
stringent levels of regulation would be appropriate.
The audit found that the current level of regulation exer-cised
by the Board of Nursing is appropriate.
12. The extent to which the Board has used private con-tractors
in the performance of its duties and how e f-fective
use of private contractors could be accom-plished.
The Board has made use of private contractors to perform
certain services. For example, the Board contracts with a
private company to administer its CNA certification
exam. Additionally, the Board contracts for its computer
support, maintenance, and Web site needs. Finally, the
Board contracts with a firm to manage the production
and distribution of the Board’s newsletter. Currently,
there do not appear to be any further opportunities to
contract services.
38
OFFICE OF THE AUDITOR GENERAL
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OFFICE OF THE AUDITOR GENERAL
AGENCY RESPONSE
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
Jane Dee Hull Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1651 East Morten, Suite 210
Phoenix. AZ 85020-4613
Phone (602) 331-8111 Fax (602) 906-9365
E-Mail: arizona@azbn.org
Website: www.azboardofnursing.org
F:\PAD\PDF Reports\2001 Reports\01-21\Final Response to SunsetAudit 2001.doc
September 7, 2001
Debbie Davenport, Auditor General
State of Arizona
Office of the Auditor General
2910 N. 44th Street, #410
Phoenix, Arizona 85018
Enclosed is the Arizona State Board of Nursing response to the sunset performance audit
completed August 31, 2001. As requested, a formal response to each recommendation contained
within the revised preliminary report is provided.
We have valued an external review of our effectiveness and efficiency as well as citing
accomplishments over the past five years. On behalf of the agency, we wish to thank the Auditor
General and staff for their professionalism when analyzing the overall performance of the Board of
Nursing. We stand ready to provide you with an implementation status report as requested.
For the Board,
Joey Ridenour, RN MN
Executive Director
Summary Response to Performance Audit
Arizona State Board of Nursing (Report Highlights)
The number of open complaints is approximately 1,750 cases of the 9,839 total cases
received at the Board from January 1996 to August 2001. In 2000, a three- year
analysis of completed investigations identified approximately 67% of the cases
investigated resulted in no discipline being imposed by the Board and 33% resulted in
disciplinary action for violations of the Nurse Practice Act. The Board has approved
policies over the past three years to improve utilization of investigative resources by
focusing on conduct assessed to be high risk or harm to the public. Cases considered
to be no or low public risk are now resolved through policies and processes adopted by
the Board; i.e. Case Disposition Criteria, Summary Letters of Concern and Triage
Criteria for Opening Investigations.
The 83 complaint investigations listed represent 2% of the 2,052 cases finalized in fiscal
year 2000. The average cycle times for all 2,052 investigations for all categories is:
RN/LPN 9 months and Certified Nursing Assistants 10 months.
The Board performance in tracking complaints and cycle times has been in place since
1997. Effective management oversight is evidenced by a 60% increase in cases to the
Board i.e. monthly average of 95 cases in 1997 to 160 cases 2001. In 1997, the eight
Nurse Consultants averaged 3.7 cases per month versus a 300% increase in fiscal year
2000 for an average of 11 cases per month.
Improved tracking and oversight of investigations was evidenced at the June 2001
meeting when the Board was presented with 357 cases (including investigations and
other items requiring Board action), which is the largest volume of cases to be heard in
the Board’s eighty-year history. Due to time factors, fifty-eight cases were tabled to the
meeting scheduled five weeks later and completed at that time.
In fiscal year 2000, the Board received four written reports on the investigations and
progress made in reducing the cycle times. The Board continues to receive quarterly
updates.
Finding I: The Board Should Improve the Timeliness of Its Complaint
Investigations
1. The Board should monitor the progress made by its additional investigator
FTE’s toward meeting performance goals.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Performance standards for number of cases to Board per
month were implemented over three years ago and all staff has been continuously
monitored for achievement of results. The additional funding for seven temporary and
two permanent positions approved by the Joint Legislative Budget Committee in FY
2001 was data driven and formulated based on the prior four-year data on investigator
performance outcomes.
2. The Board should establish internal time frames for each phase of its
investigations, with the total number of days from complaint receipt through
adjudication being no longer than 180 days.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. The six-month goal for completion of investigations was set by
the Board in February 2000 with continuous monitoring of progress to date. Average
cycle times for RN/LPN investigations is 9 months and Certified Nursing Assistants is 10
months.
3. While working to clear its open investigations, the Board should ensure that,
at a minimum, all priority 1 investigations adhere to the established investigation
process time frames.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff.
4. The Board should generate management reports that track the status of
open complaint investigations.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Monitoring of open cases will include prescribed days for each
phase of the investigative process but the focus will continue to be on results per
investigator as cases are decided by Board action.
5. The Board should consider options, such as dividing into two panels or
subcommittees to review complaints or meeting more frequently, in order to
adjudicate in a timely manner the increased number of complaints likely to be
brought before it.
The finding of the Auditor General is agreed to and the audit recommendation was
implemented before the recommendation was made. The Board increased the annual
meeting days from 16 to 22 at the August 2001 Board Meeting.
Finding II: Board Practices Restrict Access to Public Information
1. The Board should strengthen its public information policies to guide staff in
providing public information to consumers over the telephone and in person,
including providing the number and nature of closed, dismissed, and pending
complaints and disciplinary actions.
The finding of the Auditor General is agreed to and the audit recommendation will
be implemented for all staff based on guidance from the Attorney Generals Office.
Public access to information is determined by the public records act, advice from the
Assistant Attorney General and approval of these policies by the Board. To ensure
licensee/certificate holders due process rights are protected, details of the investigative
information is considered confidential and is not released to the public until the Board
determines that a violation of the Nurse Practice Act has occurred and that discipline
may be imposed and notices are served. Federal regulations prohibit finger print criminal
history information obtained from the DPS/FBI from being secondarily released to the
public. The Assistant Attorney General is developing a draft policy regarding public
access to criminal history information, which will be presented to the Board for their
approval.
The preferred route for the majority of the public who accesses public information is
through the automated systems such as the Interactive Voice Recognition (IVR) and
Board web site available 24 hours per day. The Board currently receives an average of
1050 phone calls daily or over 288,000 annually. Over 800 of the daily calls are
members of the public directly accessing the Interactive Voice Recognition System by
entering a social security or license/certificate number to determine if an individual has an
active license or certificate, if there is a pending complaint or investigation and if there is
any disciplinary action currently imposed.
The public may also access licensee/certificate holder disciplinary actions imposed since
April 1996 through the Board’s web site. Over 1050 RN/LPNs and approximately 460
Certified Nursing Assistants have had disciplinary actions taken during the last five
years. This same public information is available through the quarterly publications of the
Arizona State Board of Nursing Newsletters sent to over 90,000
RN/LPN/CNA/student nurses in Arizona.
The Board also notifies national disciplinary data banks of disciplinary actions taken to
further protect the public. The data banks include the National Council of State Boards
of Nursing Nursys Data Bank, Health Integrity Protection Data Bank and the National
Practitioner Data Bank.
2. The Board should train staff on how to appropriately provide public
information to consumers by phone and in person.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Seventy per cent of the 1050 daily calls are routed through
and automated system to verify licenses/certificates and determine if there is a
complaint received or investigation pending.
3. The Board should eliminate its restrictive policies requiring staff to obtain
the names and other descriptive information of consumers requesting public
information
The finding of the Auditor General is agreed to and the audit recommendation has
previously been implemented for all staff.
4. The Board should ensure that nurses and CNAs know what information is
considered public, including the fact that home address are considered public
information when business addresses are not provided.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. This information was previously provided in the Quarterly
ASBN Newsletter sent out to approximately 90,000 RN/LPN/CNA/Student Nurses
in the state. The information will be repeated in future editions as well as application
instructions.
5. The Board should develop and implement a plan to route public calls, such
as adding a public information option to its automated phone system, adding
additional phone lines, or establishing a customer service unit to handle
consumer information requests.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. A consultant has already begun work to evaluate the phone
system and submit recommendations for improving the board functions. We welcome
suggestions to improve responding to the high volume of calls and making the system
more customer friendly.
Other Performance Audit Reports Issued Within
the Last 12 Months
01-10
Future Performance Audit Reports
Arizona Department of Corrections—Arizona Correctional Industries
Department of Building and Fire Safety
01-1 Department of Economic Security—
Child Support Enforcement
01-2 Department of Economic Security—
Healthy Families Program
01-3 Arizona Department of Public
Safety—Drug Abuse Resistance
Education (D.A.R.E.) Program
01-4 Arizona Department of
Corrections—Human Resources
Management
01-5 Arizona Department of Public
Safety—Telecommunications
Bureau
01-6 Board of Osteopathic Examiners in
Medicine and Surgery
01-7 Arizona Department
of Corrections—Support Services
01-8 Arizona Game and Fish Commission
and Department—Wildlife
Management Program
01-9 Arizona Game and Fish
Commission—Heritage Fund
01-10 Department of Public Safety—
Licensing Bureau
01-11 Arizona Commission on the Arts
01-12 Board of Chiropractic Examiners
01-13 Arizona Department of
Corrections—Private Prisons
01-14 Arizona Automobile Theft
Authority
01-15 Department of Real Estate
01-16 Department of Veterans’ Services
Arizona State Veteran Home,
Veterans’ Conservatorship/
Guardianship Program, and
Veterans’ Services Program
01-17 Arizona Board of Dispensing
Opticians
01-18 Arizona Department of Correct-ions—
Administrative Services
and Information Technology
01-19 Arizona Department of Education—
Early Childhood Block Grant
01-20 Department of Public Safety—
Highway Patrol

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State of Arizona
Office
of the
Auditor General
PERFORMANCE AUDIT
Report to the Arizona Legislature
By Debra K. Davenport
Auditor General
BOARD
OF
NURSING
September 2001
Report No. 01-21
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee
composed of five senators and five representatives. Her mission is to provide independent and impar-tial
information and specific recommendations to improve the operations of state and local government
entities. To this end, she provides financial audits and accounting services to the state and political
subdivisions and performance audits of state agencies and the programs they administer.
The Joint Legislative Audit Committee
Senator Ken Bennett, Chairman
Representative Roberta L. Voss, Vice-Chairman
Senator Herb Guenther Representative Robert Blendu
Senator Dean Martin Representative Gabrielle Giffords
Senator Peter Rios Representative Barbara Leff
Senator Tom Smith Representative James Sedillo
Senator Randall Gnant (ex-officio) Representative James Weiers (ex-officio)
Audit Staff
Dale Chapman—Manager
and Contact Person (602) 553-0333
Ann Orrico—Team Leader
Joseph McKersie—Team Member
Kristin Borns—Team Member
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
(602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
September 12, 2001
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Ms. Joey Ridenour, Executive Director
Arizona State Board of Nursing
Transmitted herewith is a report of the Auditor General, A Performance Audit of the Board of
Nursing. This report is in response to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. The performance audit was conducted as part of the Sunset review set forth in
A.R.S. §41-2951 et seq. I am also transmitting with this report a copy of the Report Highlights
for this audit to provide a quick summary for your convenience.
As outlined in its response, the Board of Nursing agrees with all of the findings and plans to
implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on September 13, 2001.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
OFFICE OF THE AUDITOR GENERAL
Program Fact Sheet
Board of Nursing
Services: The Board of Nursing (Board) is responsible for regulating nurses and certified
nursing assistants (CNAs) through licensure and certification. The Board performs the fol-lowing
services: 1) Approving individuals for licensure, registration, and certification; 2)
Approving educational programs for nurses and nursing assistants; 3) Investigating and
adjudicating complaints concerning allegations of unprofessional conduct or other viola-tions
of the Nurse Practice Act; and 4) Providing consumer information to the public.
Program Operations Revenue1:
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
1999 2000 2001
Other(2)
Intergovernmental(3)
Fines and forfeits
Licenses, fees, and permits
1 The Board retains 90 percent of its revenues for oper-ating
and remits all of its administrative penalties and
10 percent of all other revenues into the General Fund.
2 For fiscal year 2000, includes a $320,000 General Fund
appropriation to pay for fingerprinting certified nurs-ing
assistant applicants.
3 Consists of federal monies for nursing assistant certi-fication.
Facilities:
The Board owns no facilities. The Board’s
office is located in a state-owned building
at 1651 E. Morten, in Phoenix. Board meet-ings
are held at this location.
Personnel:
The Board consists of nine members who
serve five-year terms:
n Five registered nurses who have at
least five years’ experience in nursing
following graduation and have been
actively engaged in the practice of
nursing for at least five years prior to
the appointment.
n Two licensed practical nurses who
must also have five years’ nursing
experience and have been actively
engaged in nursing at least three
years prior to the appointment; and
n Two public members who are not
employees of any health care institu-tion
and do not have a financial inter-est
as a provider in the delivery of
health care services.
As of July 1, 2001, the Board had 53.8 full-time
staff:
¾ Administration and Support Staff (23)
¾ Licensing (9)
¾ Investigations/Adjudication (21.8)
OFFICE OF THE AUDITOR GENERAL
Agency Mission:
“To protect the public
health, safety, and welfare
through the safe and com-petent
practice of nursing
and nursing assistants.”
Equipment:
In addition to owning standard office
equipment, the Board also rents a vehicle
from the Department of Administration for
$403 per month.
Program Goals (Fiscal Year 2000-2001):
The Board of Nursing consists of the fol-lowing
two programs:
Licensing and Regulation—RN/LPN:
1. To reduce the cycle time needed to is-sue
certificates and licenses for exami-nee,
endorsement, and renewal appli-cants.
2. To reduce the cycle time needed to in-vestigate
complaints, complete hear-ings,
and increase compliance with
consent agreements and Board orders.
3. To effectively provide a non-disciplinary
Chemically Addicted
Nurse Diversion Option (CANDO)
program.
4. To provide an effective educational
program monitoring process for
schools of nursing that promotes a high
percentage of RN/LPN examinees
passing NCLEX (a national licensure
exam for RNs and LPNs).
Nursing Assistant:
1. To reduce the cycle time needed to is-sue
certificates for examinee, endorse-ment,
and renewal applicants.
2. To reduce the cycle time needed to in-vestigate
complaints, complete hear-ings,
and increase compliance with
consent agreements and Board orders.
Adequacy of Performance Measures:
The Board has established appropriate per-formance
measures within its Licensing
and Regulation—RN/LPN and Nursing
Assistant programs. For example, the
Board has established measures focusing
on its licensing, certification, and complaint
investigation activities; the timeliness and
results of those activities; and customer sat-isfaction
with these efforts.
i
OFFICE OF THE AUDITOR GENERAL
SUMMARY
The Office of the Auditor General has conducted a performance
audit and Sunset review of the Board of Nursing (Board) pursu-ant
to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. This audit was conducted under the authority
vested in the Auditor General by Arizona Revised Statutes
(A.R.S.) §41-2951 et seq.
The Board is responsible for regulating registered nurses (RNs),
licensed practical nurses (LPNs), and certified nursing assistants
(CNAs). The Board’s duties include issuing and renewing li-censes,
conducting investigations and hearings concerning un-professional
conduct, disciplining violators, and providing con-sumer
information to the public. As of July 2001, the Board li-censes
approximately 47,300 RNs, including 2,350 RNs certified
as advanced practice nurses, and 9,320 LPNs and certifies ap-proximately
18,600 CNAs. Further, the Board reports that it re-ceived
approximately 2,200 complaints in fiscal year 2000.
The Board Should Improve
the Timeliness of Its Complaint
Investigations
(See pages 11 through 18)
The Board should take several steps to ensure complaints are in-vestigated
in a timely manner. Auditors’ review of 83 complaint
investigations presented to the Board in fiscal year 2000 for adju-dication
found that the Board’s investigation times ranged from
32 days to 1,938 days, with over half of these investigations tak-ing
longer than 360 days.1 In addition, as of August 2001, the
1 The 83 investigations reviewed did not include investigations that arose as
a result of information disclosed on license/certificate applications or
background checks. When these investigations are combined with com-plaint
investigations, the Board reports that it takes an average of nine to
ten months to complete an investigation.
Summary
ii
OFFICE OF THE AUDITOR GENERAL
Board had approximately 1,750 open investigations, including
hundreds of investigations that were initiated prior to 2000. For
example, 122 investigations initiated in 1997 remain unresolved
as of August 2001. The Board’s long investigation time frames
represent a risk to the public because nurses and CNAs under
investigation can continue to practice for long periods without
receiving appropriate discipline and addressing the identified
problems.
In 1995, the Board received regulatory responsibility for investi-gating
CNA complaints and certification applications. This in-creased
the number of investigations it conducts, and affected
the Board’s ability to investigate complaints in a timely manner.
In fact, of the approximately 1,750 open investigations as of Au-gust
2001, over 1,200 are related to CNAs. To help it complete the
large number of open complaint investigations, the Board re-quested
and received $772,700 over fiscal year 2001 and fiscal
year 2002 to hire nine additional investigators. However, seven
of these investigator positions are temporary and will terminate
after June 2002.
While the Board has hired additional investigative staff, it can
take several other steps to improve its investigation timeliness.
First, the Board should monitor the progress of its additional in-vestigative
staff to ensure that it eliminates as many open inves-tigations
as possible before it loses the seven temporary investi-gators.
Second, the Board should develop and implement inter-nal
time frames for each stage of its investigation process. While
it may take time for the Board to adhere to these time frames be-cause
of the large number of open investigations, the Board
should, at a minimum, ensure that high-priority complaint in-vestigations
(those alleging patient harm) adhere to the estab-lished
time frames. Further, the Board should generate monthly
management reports to ensure that internal time frames are met
and complaints are investigated in a timely manner. Finally, be-cause
the number of complaints ready for adjudication at each
Board meeting will likely increase, the Board should consider
options, such as dividing into two panels or subcommittees or
meeting more frequently, to adjudicate these cases in a timely
manner.
Summary
iii
OFFICE OF THE AUDITOR GENERAL
Board Practices Restrict
Access to Public Information
(See pages 19 through 23)
The Board does not provide appropriate access to public infor-mation
regarding nurses and CNAs. Specifically, auditors posing
as members of the public phoned the Board and requested in-formation
on five different licensees/certificate holders. Two
auditors’ requests were handled appropriately. However, in one
instance, the Board failed to disclose to the auditor the nature of a
pending complaint against a CNA. Further, another auditor was
not informed of a nurse’s dismissed complaint. Finally, one audi-tor
was not able to obtain any complaint or disciplinary informa-tion
despite phone calls and a visit to the Board’s offices. Unim-peded
access to public information about nurses and CNAs is an
important regulatory board function as it helps consumers select
competent and ethical professionals.
In addition, certain Board practices further impede consumers’
access to public information. According to policy, Board staff
must ask consumers for information such as their name, tele-phone
number, and reason for requesting public information.
While the Board has established this practice to protect the safety
of nurses and CNAs because their home addresses may be con-sidered
public information if a business address is not provided,
it may deter consumers from making public information re-quests.
Further, the Board’s automated phone system is difficult
to navigate and does not provide easy access to the appropriate
staff to handle consumers’ requests.
Other Pertinent Information
(See pages 25 through 29)
During the audit, other pertinent information was gathered in
response to legislative inquiries concerning the Board’s regula-tion
of CNAs. The regulation of nursing assistants resulted from
the federal government’s 1987 Omnibus Reconciliation Act (Act).
The purpose of the Act is to protect individuals in nursing homes
and other federally funded long-term care facilities from im-properly
trained nursing assistants. The Act establishes certain
minimum requirements for certifying and regulating nursing
Summary
iv
OFFICE OF THE AUDITOR GENERAL
assistants. To help offset some of the costs of regulating CNAs,
the Act provides federal monies to states, but does not allow
states to charge nursing assistants for certification costs.
Auditors’ review of other states’ CNA regulatory structures
found that Arizona is 1 of 14 states that regulate CNAs through
boards of nursing. Arizona adopted this regulatory structure be-cause
the Board already had established processes for licensing
nurses that could be used for certifying nursing assistants. Other
common regulatory models among the 50 states include health
facility regulatory agencies, such as Indiana’s Department of
Health, Division of Long Term Care, or occupational licensing
and regulatory agencies, such as Alaska’s Division of Occupa-tional
Licensing, which licenses multiple occupations, from acu-puncturists
to public accountants.
While the Board initially struggled with the responsibility of
regulating CNAs because of the increased workload, it has since
received additional resources to help perform its regulatory re-sponsibilities.
For example, the Board has established a fee for
optional CNA cards that show proof of current certification and
has also received State General Fund monies to cover the ex-pense
of fingerprinting CNAs for certification background
checks. In addition, the Board hired more investigators, although
most are temporary positions, to assist it in completing its large
number of open CNA-related investigations.
v
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS
Page
Introduction and Background............................. 1
Finding I: The Board Should
Improve the Timeliness of Its
Complaint Investigations................................ 11
Slow Investigations Decrease
Board’s Public Protection
Efforts.................................................................................. 11
Three Factors Affect Board’s
Ability to Investigate Complaints
In a Timely Manner............................................................ 14
Changes Needed to Improve
Investigation Timeliness and
Reduce Number of Open
Investigations ..................................................................... 16
Recommendations ............................................................. 18
Finding II: Board Practices
Restrict Access to Public
Information ...................................................... 19
Providing Public Information
Is an Important Part of a
Regulatory Board’s Responsibilities.................................. 19
Board Needs To Provide More
Complete Public Information............................................ 19
Board Should Provide Easier
Access To Public Information............................................ 21
Recommendations ............................................................. 23
Table of Contents
vi
OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS (Concl’d)
Page
Other Pertinent Information................................. 25
Regulating Certified
Nursing Assistants............................................................. 25
Sunset Factors..................................................... 31
Agency Response
Items
Item 1 Licenses and Certificates
Issued by the Board.......................................... 2
Item 2 Complaint Priorities......................................... 4
Item 3 Open Investigations
As of August 2001
By Year of Receipt............................................ 12
Item 4 Nursing Assistants’ Duties.............................. 25
Table
Table 1 State Board of Nursing
Statement of Revenues, Expenditures,
and Changes in Fund Balance
Years Ended June 30, 1999, 2000, and 2001
(Unaudited)...................................................... 7
1
OFFICE OF THE AUDITOR GENERAL
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance
audit and Sunset review of the Board of Nursing (Board) pursu-ant
to a June 16, 1999, resolution of the Joint Legislative Audit
Committee. This audit was conducted under the authority
vested in the Auditor General by Arizona Revised Statutes
(A.R.S.) §41-2951 et seq.
Board Responsibilities
Since its inception in 1921, the Board of Nursing has been re-sponsible
for regulating registered nurses (RNs) through licen-sure.
In 1952, the Board’s responsibilities were expanded when
licensed practical nurses (LPNs) were added to the Board’s regu-latory
responsibilities. In 1990, as a result of federal requirements,
the Board received the responsibility for certifying nursing assis-tants
(CNAs). This responsibility for CNAs was expanded in
1995, when the Board received statutory authority to regulate
CNAs. Item 1 (see page 2) lists the primary licenses and certifi-cates
the Board is responsible for issuing. The Board offers addi-tional
credentials for RNs, including certification for advanced
practice nurses, such as nurse practioners and clinical nurse spe-cialists,
as well as prescribing privileges that allow advanced
practice nurses to prescribe and dispense drugs or medication to
patients.
The Board’s mission is:
“To protect the public health, safety, and welfare
through the safe and competent practice of nursing and
nursing assistants.”
Introduction and Background
2
OFFICE OF THE AUDITOR GENERAL
The Board accomplishes this mission by performing a variety of
functions, including:
n Issuing and renewing licenses and certificates to persons who
practice nursing or act as nursing assistants and possess the
required qualifications;
n Conducting investigations and hearings concerning unpro-fessional
conduct or other violations of the Nurse Practice
Act;1
n Disciplining violators; and
n Providing consumer information to the public.
1 The Nurse Practice Act consists of the Board’s statutes and rules and gov-erns
the licensure and regulation of RNs, LPNs, and CNAs.
Item 1: Licenses and Certificates
Issued by the Board
¾ Registered Nurse (RN): RNs are professional nurses who have
obtained an associate’s or bachelor’s degree in nursing or a di-ploma
from a professional nursing program. Typical duties in-clude
observing, assessing, and recording symptoms, reactions,
and progress; developing and managing nursing care plans;
administering medications; assisting physicians during treat-ments
or examinations; instructing patients in proper care; and
supervising LPNs and CNAs.
¾ Licensed Practical Nurse (LPN): LPNs must complete a one-year
practical nursing training program and provide care only
under the supervision of an RN or licensed physician. Typical
duties include taking vital signs, such as temperature and blood
pressure; giving injections; and observing, recording, and re-porting
a patient’s condition to his/her supervisor. However,
LPNs cannot provide an assessment of the patient’s condition.
¾ Certified Nursing Assistant (CNA): To become certified, nurs-ing
assistants must complete 120 hours of training. Typical du-ties
include assisting patients with eating, dressing, bathing, and
walking. A CNA may not perform any task requiring judgment
based on nursing knowledge, such as administering medica-tions.
Introduction and Background
3
OFFICE OF THE AUDITOR GENERAL
As of July 2001, the Board licenses approximately 47,300 RNs,
including 2,350 RNs certified as advanced practice nurses, and
9,320 LPNs and certifies approximately 18,600 CNAs.
Statutory Licensure
Requirements
The Board’s statutes contain the following general education and
examination requirements for licensure as an RN or LPN or certi-fication
as a CNA:
n Graduating from an approved professional nursing, practical
nursing, or nursing assistant program. These include schools
or colleges that award degrees in professional or practical
nursing and that are approved by the Board and/or are ac-credited
by a national nursing accrediting agency. This also
includes schools or nursing care facilities that issue certifi-cates
in nursing assistant training that are approved by the
Board and/or are accredited by a national accrediting
agency. Currently, there are 22 schools in Arizona offering
degrees in professional and/or practical nursing and ap-proximately
150 nursing assistant training programs.
n Passing an approved examination administered by a private
testing company, or possessing an unrestricted license or cer-tificate
from another state, district, or territory with similar
standards.
In addition to the general education and examination require-ments,
statute requires candidates for licensure or certification
who have been convicted of one or more felonies to have com-pleted
the sentences for all felony convictions and received abso-lute
discharge five or more years before they file an application
with the Board.
Complaint Resolution
The Board investigates and adjudicates complaints involving
violations of the Nurse Practice Act, such as potential unprofes-sional
conduct by nurses and CNAs. A.R.S. §32-1601 defines the
Introduction and Background
4
OFFICE OF THE AUDITOR GENERAL
actions that constitute unprofessional conduct for nurses and
CNAs, including such
things as any conduct or
practice that is or might be
harmful or dangerous to the
health of a patient or the
public. When Board staff
receive a complaint alleging
that a nurse or CNA vio-lated
a provision of the
Nurse Practice Act, they
open an investigation. In
addition, the Board investi-gates
criminal and discipli-nary
histories of current li-cense
or certificate holders and applicants. Specifically, the Board
conducts investigations when background checks reveal, or the
nurse or CNA discloses, the presence of criminal activity or dis-ciplinary
action taken against a nurse’s or CNA’s license or cer-tificate
in another state.
Prior to beginning an investigation, the Board’s executive direc-tor
or associate director reviews complaints and assigns them an
investigation priority. As seen in Item 2, a complaint can be as-signed
one of three different priority levels depending on the se-riousness
of the allegations, with priority 1 being the highest. An
investigation includes obtaining a response to the complaint
from the accused nurse or CNA; subpoenaing relevant records,
such as employment, medical, or motor vehicle records; and in-terviewing
the accused nurse or CNA, the complainant, and any
pertinent witnesses. After the investigation is completed, the
Board reviews the complaint and adjudicates it. At this time, the
named nurse or CNA has the opportunity to address the Board.
The Board votes to resolve each complaint using one of its statu-tory
nondisciplinary or disciplinary options. The Board’s nondis-ciplinary
options for nurses and CNAs are:
n Dismissing the complaint; or
n Issuing a Letter of Concern.
Item 2: Complaint
Priorities
Priority 1: Complaints that pose im-mediate
danger to public safety and
must be investigated immediately,
including chemical use while on duty
and all sexual allegations.
Priority 2: Complaints that are serious
but pose less of a threat than priority 1
complaints. Includes allegations of
abuse, negligence, and incompetence.
Priority 3: Complaints that pose little
to no threat of harm to public safety.
Investigating and adjudi-cating
complaints is a
major Board responsibil-ity.
Introduction and Background
5
OFFICE OF THE AUDITOR GENERAL
If the Board votes to impose discipline, its options for nurses are:
n Issuing a Decree of Censure;
n Imposing a term of probation, which can include require-ments
for mental, physical, or psychological examinations,
bodily fluids testing, or educational requirements;
n Imposing civil penalties; or
n Suspending or revoking the nurse’s license.
The Board’s disciplinary options for CNAs are:
n Imposing civil penalties; or
n Suspending or revoking the CNA’s certificate.
In addition, as authorized by statute, the Board operates a confi-dential,
nondisciplinary program for nurses with chemical de-pendencies,
known as the Chemically Addicted Nurses Diver-sion
Option (CANDO). If the Board receives a complaint against
a nurse indicating that the nurse is chemically dependent, the
nurse can voluntarily enter the CANDO program before an in-vestigation
is initiated. To participate in the CANDO program,
the nurse must enter into an agreement with the Board that con-tains
stipulations, such as participating in the program for at
least three years, completely abstaining from alcohol and all
other mind/mood-altering medications and controlled and/or
addictive substances, and entering a Board-acceptable chemical
dependency treatment program. While many nurses opt to par-ticipate
in CANDO as a result of a complaint against them, they
can also voluntarily enter the program even though no com-plaints
have been filed.
Organization and Staffing
The Board consists of nine governor-appointed members who
serve five-year terms. Five of the members must be registered
nurses, two members must be licensed practical nurses, and two
members must represent the public.
Introduction and Background
6
OFFICE OF THE AUDITOR GENERAL
In fiscal year 2001, the Board is authorized 53.8 full-time equiva-lent
(FTE) positions. This includes nine investigator FTEs re-cently
assigned to the Board to help it address its large number
of open investigations, seven of which are two-year temporary
positions (see Finding I, pages 11 through 18). Board staff also
includes an executive director, an associate director responsible
for operations, an associate director responsible for investiga-tions,
and several legal secretaries, licensing technicians, and
other support staff.
Budget
The Legislature establishes an expenditure limit on monies the
Board collects and deposits in the Board of Nursing Fund. This
fund contains revenues derived principally from the collection of
licensure application and renewal fees. The Board deposits 90
percent of its revenues into the fund and the remaining 10 per-cent
into the State’s General Fund.
In November 2000, the Board requested that the Legislature ap-propriate
additional monies from the Board’s fund to allow it to
hire additional investigators to help address its large number of
investigations.1 In response to this request, the Legislature ap-propriated
$772,700 from the Board’s fund over fiscal years 2001
and 2002. This is enough to hire nine investigator FTEs. Table 1
(see page 7) illustrates the Board’s actual revenues and expendi-tures
for fiscal years 1999 through 2001.
1 This request was made pursuant to a provision of the General Appropria-tion
Act, which allows 90/10 boards to request an additional $50,000 or 20
percent of the board’s current fiscal year appropriation when faced with
unanticipated costs. This allows boards to access monies from their funds
without having to request a supplemental appropriation during the regu-lar
legislative session.
The Board received addi-tional
money in fiscal year
2001 to hire more investi-gators.
Introduction and Background
7
OFFICE OF THE AUDITOR GENERAL
Table 1
State Board of Nursing
Statement of Revenues, Expenditures, and Changes in Fund Balance
Years Ended June 30, 1999, 2000, and 2001
(Unaudited)
1999 2000 2001
Revenues:
Licenses, fees, and permits $2,111,536 $2,322,432 $3,247,968 1
Intergovernmental 408,608 436,159 209,700
State General Fund appropriation 2 321,200
Fines and forfeits 147,782 120,653 130,908
Other 186,411 236,105 198,380
Total revenues 2,854,337 3,436,549 3,786,956
Expenditures:
Personal services 3 1,295,358 1,640,785 1,831,238
Employee-related 3 249,109 315,697 348,705
Professional and outside services 4 283,642 430,648 447,456
Travel, in-state 24,180 12,977 19,379
Travel, out-of-state 5,542 13,397 16,362
Other operating 303,138 335,154 421,092
Equipment 53,434 80,859 259,595
Total expenditures 2,214,403 2,829,517 3,343,827
Excess of revenues over expenditures 639,934 607,032 443,129
Other financial sources (uses):
Net operating transfers in (out) (4,712) (4,213) 98,731
Remittances to the State General Fund 5 (264,587) (274,395) (367,277)
Total other financing uses (269,299) (278,608) (268,546)
Excess of revenues expenditures and other
financing uses 370,635 328,424 174,583
Fund balance, beginning of year 1,933,297 2,303,932 2,632,356
Fund balance, end of year $2,303,932 $2,632,356 $2,806,939
1 Amount increased significantly from 2000 because the Board raised licensing fees when it extended licenses for registered
nurses and licensed practical nurses to three years.
2 The Board received a one-time State General Fund appropriation in 2000 to pay for fingerprinting certified nursing assis-tant
applicants. As of June 30, 2001, the Board’s unexpended $90,179 is included in the end of year fund balance.
3 Personal services and employee-related expenditures increased for nine new full-time equivalent (FTE) positions author-ized
by the Legislature in 2000 and another nine FTE positions in 2001.
4 Professional and outside services for 2000 and 2001 include expenditures approved by the Legislature to purchase various
automation services needed to link the Board’s database file to its Web site, store applications on microfilm, and imple-ment
a document scanning system.
5 As a 90/10 agency, the Board remits all of its administrative penalties and 10 percent of all other revenues to the State
General Fund.
Source: Auditor General staff analysis of the Arizona Financial Information System Revenues and Expenditures by Fund, Pro-gram,
Organization, and Object, Trial Balance by Fund, and Status of Expenditures and Appropriations reports for the years
ended June 30, 1999, 2000, and 2001.
Introduction and Background
8
OFFICE OF THE AUDITOR GENERAL
Audit Scope and
Methodology
Audit work focused on the Board’s investigation and adjudica-tion
processes, public information practices, and regulation of
CNAs. This performance audit and Sunset review includes find-ings
and recommendations as follows:
n The Board needs to improve the timeliness of its complaint
investigations (see Finding I, pages 11 through 18); and
n The Board needs to strengthen its public information policies
and practices (see Finding II, pages 19 through 23).
In addition, this report contains an Other Pertinent Information
section that provides information regarding the regulation of
CNAs in Arizona (see pages 25 through 29).
This audit used a variety of methods to study the issues ad-dressed
in this report, including the following:
n To assess the timeliness of the Board’s complaint investiga-tions,
auditors reviewed a random sample of 83 complaints
that were presented to the Board for adjudication during fis-cal
year 2000. This sample included: 1) 30 dismissed com-plaints
that met Board criteria for expedited adjudication and
shortened investigation time frames; 2) 23 complaints that re-sulted
in nondisciplinary Letters of Concern and also met
Board criteria for expedited adjudication and shortened in-vestigation
time frames; and 3) 30 complaints that proceeded
through the Board’s full investigative and adjudication proc-esses.
Auditors’ review of the latter group also assessed the
quality of the Board’s investigations and the appropriateness
of the Board’s adjudication practices.
n To determine whether the Board provides consumers with
accurate and complete information about nurses or CNAs,
including complaint histories, auditors posing as members of
the public made five calls to the Board requesting informa-tion
and compared the information provided to the Board’s
complaint records.
Introduction and Background
9
OFFICE OF THE AUDITOR GENERAL
n To compare Arizona’s regulation of CNAs to other states,
auditors reviewed the CNA regulatory structures of all 50
states as reported in the February 2001 National Council of State
Boards of Nursing Directory of Nurse Aide Registries. In addition,
auditors researched the Web sites of eight states to verify the
appropriate state agency regulating CNAs because the Direc-tory
was unclear.1 Further, auditors contacted ten states rep-resenting
the various regulatory structures to obtain further
information on those structures.2
This audit was conducted in accordance with government audit-ing
standards.
The Auditor General and staff express appreciation to members
of the Board of Nursing, the executive director, and staff for their
assistance throughout the audit.
1 The following eight state Web sites were researched to verify the appro-priate
state agency regulating CNAs: Delaware, Georgia, Illinois, Maine,
Michigan, New Mexico, Tennessee, and Texas.
2 The following 10 states were contacted because they were representative of
the various CNA regulatory structures used throughout the 50 states: Cali-fornia,
Florida, Indiana, Kentucky, Louisiana, Missouri, New Jersey, Ore-gon,
Virginia, and Washington.
10
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
11
OFFICE OF THE AUDITOR GENERAL
FINDING I THE BOARD SHOULD
IMPROVE THE TIMELINESS OF
ITS COMPLAINT INVESTIGATIONS
The Board of Nursing should take several steps to ensure that
complaints are resolved in a timely manner. Extremely slow
complaint investigations and a large number of open investiga-tions
decrease the Board’s ability to protect the public. Addi-tional
CNA regulatory responsibilities, inadequate tracking of
complaint investigation progress, and high turnover among its
investigative staff have affected the Board’s ability to conduct
complaint investigations in a timely manner. Changes, such as
developing internal investigation time frames and generating
management reports, can help improve investigation timeliness.
Slow Investigations
Decrease Board’s Public
Protection Efforts
The Board’s untimely complaint investigations decrease its abil-ity
to adequately protect the public from nurses and CNAs who
violate nurse practice laws. Specifically, the Board took over 360
days to investigate over half of the cases auditors reviewed,
while it currently has approximately 1,750 open investigations.
These untimely investigations diminish the Board’s public pro-tection
efforts.
Board’s investigation time frames are excessive—Auditors’ re-view
of 83 complaints presented to the Board in fiscal year 2000
for adjudication found that many took several hundred days to
complete.1 Of the 83 cases reviewed, the Board’s investigation
times ranged from 32 days to 1,938 days, with over half of these
1 The 83 investigations reviewed did not include investigations that arose as
a result of information disclosed on license/certificate applications or
background checks. When these investigations are combined with com-plaint
investigations, the Board reports that it takes an average of nine to
ten months to complete an investigation.
Board investigation time
frames ranged from 32 to
1,938 days.
Finding I
12
OFFICE OF THE AUDITOR GENERAL
investigations taking longer than 360 days and 23 complaints re-quiring
over 1,000 days to investi-gate.
Even the most critical com-plaints
often take too long to inves-tigate.
Auditors reviewed 4 com-plaints
labeled as priority 1, which
are deemed the most critical and
usually involve patient safety is-sues,
and found that 2 took over 270
days to investigate.
The Board also has a large number
of open investigations that have not been completed for several
years. As of August 2001, the Board had approximately 1,750
open investigations, of which over 36 percent were opened prior
to 2000.1 As illustrated in Item 3, 25 investigations initiated in
1996 and 122 investigations initiated in 1997 remained unre-solved
as of August 2001. In addition, the Board reports that it
typically receives hundreds of new cases for investigation each
year, including complaints and license or certificate applicant
background investigations. In fact, during fiscal year 2000, the
Board reports opening over 2,200 new investigations.
Even when complaints are opened for investigation, they often
sit for long periods of time during the investigation. Specifically,
for the cases reviewed, auditors found significant time gaps
where no investigative work was performed. For example:
¾ A nurse employed by a nursing home accused of failing to
report patient abuse was under investigation for over three
years. The Board received the complaint in July 1997 and sent
a letter to inform the nurse of the investigation one month
later. However, no further investigative work was conducted
until the Board contacted the nurse in January 2000. Further,
the Board did not subpoena pertinent records until February
2000. The case was finally resolved in September 2000, when
the Board issued a nondisciplinary Letter of Concern.
1 This includes both complaint investigations and investigations that arose
as a result of information disclosed on license/certificate applications or
background checks.
Item 3: Open
Investigations
As of August 2001
By Year of Receipt
1996: 25 Cases
1997: 122 Cases
1998: 220 Cases
1999: 272 Cases
2000: 556 Cases
2001: 560 Cases
Board has approximately
1,750 open investigation
cases as of August 2001.
Finding I
13
OFFICE OF THE AUDITOR GENERAL
n A nurse was under investigation for over four years as a re-sult
of an anonymous complaint alleging a substance abuse
problem. The Board received the complaint in August 1995
and spoke with the nurse in November 1995 to inform her of
the option of entering the Board’s special program for chemi-cally
addicted nurses. However, no records were subpoe-naed
until February 1996, and it was not until over two-and-a-
half years later, in September 1998, that any further investi-gative
work was conducted. In March 1999, the complaint
was reassigned to another investigator who finally com-pleted
the investigation and brought the complaint to the
Board for adjudication in October of 1999. The Board voted to
dismiss the complaint.
Successfully resolving complaints can be made more difficult by
the fact that information needed to support allegations may be-come
harder to obtain as time passes. Witnesses, as well as com-plainants
and accused nurses and CNAs, forget details of the in-cidents,
or move and do not provide updated contact informa-tion.
For example, the Board did not conduct any investigative
work on one case for almost four years. Once the investigator
began working on the case, she had difficulty contacting the ac-cused
nurse. Eventually, the Board learned that the nurse had
died.
Untimely investigations lead to inadequate public protection—
Because investigations take so long, certain nurses or CNAs with
problems could continue to practice unchecked. While nurses
and CNAs are under investigation, their licenses are not re-stricted.
As a result, these individuals can continue to practice for
long periods without receiving appropriate disciplinary action
and without addressing the problems identified. In addition, the
public is not informed of the Board’s concerns with these nurses
or CNAs and is open to possible substandard care for long peri-ods.
For example:
n In October 1995, the Board received a complaint that a psy-chiatric
facility nurse sent a 17-year-old inmate with a history
of recent suicide attempts back to his cell, without calling a
psychiatrist and without instituting proper precautions. The
inmate committed suicide within an hour of speaking with
the nurse. The complaint also alleged that the nurse had al-
Finding I
14
OFFICE OF THE AUDITOR GENERAL
tered the inmate’s medical chart. Despite the seriousness of
these allegations, the Board took nearly four years to com-plete
its investigation. In September 1999, the Board voted to
place the nurse on probation for 36 months with stipulations
that she could not work with children or adolescents and
could not work in any psychiatric settings. However, during
the course of the investigation, the nurse continued to work
unrestricted for at least four different employers.
n In June 1996, the Board received a complaint that a nurse was
administering medication without a doctor’s orders and was
disposing of unused narcotics without proper witnesses or
documentation, as required by policy. During a lag in the in-vestigation,
a second complaint was received in March 1997
alleging that this nurse again failed to properly account for
two doses of narcotics and that four doses of an anti-anxiety
medication meant for her patients were missing during her
shift. Additionally, during the investigation period, the nurse
disclosed a shoplifting conviction on her license renewal ap-plication.
Despite these two complaints, this case was not
heard by the Board until October 1999, when it decided to
place the nurse on an 18-month probation that required
counseling and direct supervision.
Three Factors Affect Board’s
Ability to Investigate Complaints
In a Timely Manner
Three factors affect the Board’s ability to conduct investigations
in a timely manner. First, an increase in CNA regulatory respon-sibilities
has resulted in an increase in the number of investiga-tions
the Board must conduct each year. In addition, Board staff
do not track the progress of investigations to ensure they are
completed in a timely manner. Finally, high turnover among in-vestigative
staff in fiscal years 1999 and 2000 further hampered
the Board’s ability to conduct timely investigations.
Increased CNA regulatory responsibilities affect Board’s inves-tigation
timeliness—Changes in the Board’s CNA regulatory
responsibilities have contributed to its inability to investigate
complaints in a timely manner. Specifically, in 1995, the Board
Finding I
15
OFFICE OF THE AUDITOR GENERAL
became responsible for investigating complaints alleging viola-tions
of the Nurse Practice Act by CNAs. Further, in January
1999, the Board was given responsibility for conducting back-ground
checks on CNAs, as well as RNs and LPNs, and investi-gating
issues arising from these checks, such as undisclosed
criminal convictions. These expanded CNA responsibilities in-creased
the number of investigations the Board conducts each
year. In fact, the Board reports that the number of investigations
it must conduct has tripled since 1995. Prior to the added CNA
responsibilities, the Board reports that it received an average of
47 complaints for investigation each month. However, for fiscal
year 2000, the Board reports that it received an average of 188
investigations arising as a result of complaints or licensing back-ground
checks each month. In addition, of the approximately
1,750 investigations open as of August 2001, over 1,200 are re-lated
to CNAs. (See Other Pertinent Information, pages 25
through 29, for more information on the Board’s regulation of
CNAs.)
Board staff do not monitor investigation progress—Board staff
do not currently monitor the progress of its investigations to en-sure
that they are timely. Specifically, while the Board has spe-cific
procedures that investigators must follow when conducting
investigations, there are no time frames attached. As a result, as
seen in some of the previous examples, investigators may open
an investigation by sending initial letters to the complainant and
respondent, but then not work an investigation for months or
even years because they receive other complaints that may be of
higher priority or are having problems obtaining documents or
locating respondents or witnesses. In addition, while the Board
has a computer system that is designed to capture data on com-plaints
and investigations, it does not currently provide man-agement
with accurate and complete information on the status of
investigation. As result, most investigators do not enter data into
the system. Aware of its computer problems, the Board re-quested
and has received additional monies in fiscal year 2002 to
update its computer system.
Investigative staff turnover hampered timeliness—Finally, sig-nificant
turnover among investigative staff has affected the
Board’s ability to investigate complaints in a timely manner. In
fiscal year 1999, 7 of the Board’s 19 investigators left their posi-
Board’s increased CNA
responsibilities have in-creased
its investigations
workload.
Finding I
16
OFFICE OF THE AUDITOR GENERAL
tions. Further, while the Board received an additional 3 investi-gator
positions in fiscal year 2000, giving it a total of 22 investiga-tors,
4 of these positions were vacated during that fiscal year. Ac-cording
to Board officials, these vacancies create skill losses that
often take 9 to 12 months of training to replace.
Changes Needed to Improve
Investigation Timeliness and Reduce
Number of Open Investigations
The Board should take several steps to improve its investigation
timeliness and reduce the number of open complaint investiga-tions.
Specifically, while the Board has completed an important
step toward reducing the number of open complaint investiga-tions
by requesting and receiving additional investigators, it
should monitor the progress of its investigators to ensure that its
complaint investigation goals are met. In addition, the Board
should develop internal time frames for each stage of the investi-gative
process and take steps to ensure that its computer system
can generate reports to help it better oversee and monitor its
complaint investigations. Finally, the Board should consider op-tions
for ensuring that it can adjudicate the additional complaints
in a timely manner.
Monitor progress of additional investigation resources—The
Board should monitor its progress in using the additional inves-tigative
resources it obtained to help it address its numerous
open complaint investigations. In fiscal year 2001, the Board re-quested
and the Legislature granted additional funding for more
investigators to assist the Board in completing its large number
of open investigation cases. Specifically, the Legislature ap-proved
$271,700 for fiscal year 2001 and $501,000 for fiscal year
2002 from the Board’s fund to pay for nine additional investiga-tor
FTEs. However, seven of these additional FTEs are only tem-porary,
two-year positions. To make the best use of these tempo-rary
staff, the Board has implemented an informal plan, includ-ing
performance goals, to help it reduce the number of open
complaint investigations. This plan includes using these staff to
assist the Board’s existing investigative staff in resolving current
investigations. To ensure that this plan is effectively carried out,
and to eliminate as many open complaint cases as possible be-
Board received additional
monies for seven tempo-rary
and two permanent
investigator positions.
Finding I
17
OFFICE OF THE AUDITOR GENERAL
fore June 30, 2002, when it will lose the seven temporary investi-gators,
the Board should monitor its progress in meeting the per-formance
goal of having each new investigator complete at least
ten investigations each month.
Develop internal time frames for each stage of the investigation
process—The Board should establish internal time frames for
each phase of its investigation process to help ensure timely in-vestigations.
Creating deadlines for different phases of the proc-ess
could assist the Board in ensuring that cases are not unat-tended
for extended periods. When developing these internal
time frames, the Board should ensure that the number of days
from complaint receipt to adjudication is no longer than 180
days. One hundred eighty days is a reasonable amount of time to
investigate and adjudicate complaints based on auditors’ review
of complaint investigation and adjudication time frames used by
other health regulatory boards.
Until the Board eliminates the numerous complaint investiga-tions
currently open, it may be difficult for Board staff to make
certain all investigations meet implemented time frames. How-ever,
the Board needs to establish time frames and, at a mini-mum,
make certain that all priority 1 cases meet them.
Ensure data management system provides for investigation
monitoring—The Board should ensure that changes to its com-puter
software are made and include the capability to generate
accurate reports that management can use to monitor the status
of open investigations. Once these computer system changes are
completed, the Board should generate monthly management re-ports
to help it track investigation timeliness by ensuring that the
internal time frames for each stage of the investigative process
are met.
Consider options for adjudicating complaints in a timely man-ner—
Because the nine additional investigators will likely in-crease
the number of cases requiring adjudication, the Board
may need to adopt alternative complaint resolution methods to
ensure that it can address the increased workload. Currently, the
Board meets every four to six weeks for two full days and is able
to resolve all complaints that have completed investigations.
During March, April, and May 2001, the Board addressed an av-
Board should develop
time frames to help
ensure it can complete
investigations in a
timely manner.
Finding I
18
OFFICE OF THE AUDITOR GENERAL
erage of 160 investigative cases and other adjudication matters
during each meeting. To help it address complaints in a timely
manner, the Board has implemented time-saving measures, such
as mass dismissal of complaints that it determines to be without
merit. However, now that the Board’s new investigators are ex-pected
to complete at least 10 investigations each to bring to the
Board for adjudication at each Board meeting, the number of
cases the Board will need to address could increase by as many
as 90 cases each month. In fact, during its June 2001 meeting, the
Board was presented with 357 cases, including investigations
and other items requiring Board action, but had to postpone tak-ing
action on 58 cases because it did not have sufficient time to
address them. Therefore, if the Board determines it cannot re-solve
all investigated complaints in a timely manner, it should
consider additional adjudication options. For example, the Board
could divide into two panels or subcommittees to review com-plaints
or meet more frequently to address the increased number
of complaints that will be brought before it.
Recommendations
1. The Board should monitor the progress made by its addi-tional
investigator FTEs toward meeting performance goals.
2. The Board should establish internal time frames for each
phase of its investigations, with the total number of days
from complaint receipt through adjudication being no longer
than 180 days.
3. While working to clear its open investigations, the Board
should ensure that, at a minimum, all priority 1 investiga-tions
adhere to the established investigation process time
frames.
4. The Board should generate management reports that track
the status of open complaint investigations.
5. The Board should consider options, such as dividing into two
panels or subcommittees to review complaints or meeting
more frequently, in order to adjudicate in a timely manner
the increased number of complaints likely to be brought be-fore
it.
19
OFFICE OF THE AUDITOR GENERAL
FINDING II BOARD PRACTICES
RESTRICT ACCESS TO
PUBLIC INFORMATION
The public does not have appropriate access to information re-garding
nurses and CNAs. Auditor test phone calls found that
the Board was inconsistent in its provision of public information
about licensees and certificate holders because its policies and
procedures are not clear as to how staff should respond to public
information requests. In addition, certain Board practices, such as
asking consumers for their name and phone number, as well as
the manner in which phone calls are routed, impedes consum-ers’
access to public information. Therefore, the Board should
strengthen its policies to clarify what information can be pro-vided
to consumers and should eliminate its restrictive practices.
Providing Public Information
Is an Important Part of a Regulatory
Board’s Responsibilities
One important part of a regulatory board’s responsibilities is
providing information that allows the public to make informed
decisions about utilizing the services of licensees or certificate
holders regulated by the board. For example, by informing the
public of the disciplinary actions taken against licensees or cer-tificate
holders, boards assist consumers in selecting competent
and ethical professionals. Public records laws were developed in
part to help ensure that boards make this necessary information
available.
Board Needs to Provide More
Complete Public Information
The Board’s inconsistent practices impede consumer access to
public information. Specifically, auditor test calls to the Board
Finding II
20
OFFICE OF THE AUDITOR GENERAL
resulted in varied responses, with some auditors being able to
obtain appropriate information about nurses and CNAs while
others were given incomplete information. To ensure that con-sumers
consistently have appropriate access to public informa-tion
about nurses and CNAs, the Board should strengthen its
public information policies and practices.
Auditor tests found the Board’s public information practices
varied—Five auditors posing as members of the public phoned
the Board and requested information on five different licen-sees/
certificate holders. While two of the auditors’ requests for
information were appropriately handled by the Board, the Board
did not fully disclose all available public information to the other
three auditors. In one case, the Board refused to provide infor-mation
on the general nature of a pending investigation. In an-other
case, the Board failed to inform the auditor that a nurse
with a letter of concern was the subject of a dismissed complaint.
Finally, another auditor was unable to obtain any complaint or
disciplinary information regarding a nurse, despite phone calls
and a visit to the Board’s offices. Specifically, one auditor was
told that complaint and disciplinary information could not be
provided over the phone and an appointment must be made to
view the nurse’s records at the Board’s offices. After unsuccess-fully
attempting for two weeks to make an appointment to view
the records, the auditor went to the Board’s offices. The auditor
was first informed that the Board would not release the informa-tion
she was requesting and was then told she could not see the
file; rather, she could only get copies of the nurse’s file at a cost
of $.50 per page.
Strengthen public information policies and practices—To help
ensure consumers have access to all public information, the
Board should strengthen its policies to detail the information that
will be made available to the public and then train staff on how
to properly respond to public information requests. The Board’s
current public information policies and procedures are unclear
regarding how public information requests on dismissed or
closed complaints and disciplinary histories should be handled.
Therefore, the Board should strengthen its policies and ensure
information is provided on nurses or CNAs with dismissed or
The Board’s response to
calls requesting public
information varied.
Board should clearly de-fine
what information can
be made public.
Finding II
21
OFFICE OF THE AUDITOR GENERAL
closed complaints, including the number and nature of dis-missed
complaints and the nature and resolution of closed com-plaints.
Other state agencies and boards have developed written
policies to make this information available by phone. For in-stance,
the Board of Psychologist Examiners has policies requir-ing
staff to provide the public with information over the tele-phone
regarding the number and nature of both dismissed and
pending complaints, and the resolution of closed complaints.
Board Should Provide Easier
Access to Public Information
The Board should also take steps to make public information
more accessible to consumers. Currently, the Board’s policy of
asking consumers for personal information, as well as the man-ner
in which the Board routes phone calls, hinders the public’s
access to information about nurses and CNAs. The Board should
eliminate these restrictive practices to provide consumers with
easier access to public information.
Certain Board practices impede consumer access to public in-formation—
Currently, the Board has two particular practices
that impede consumers’ access to public information on nurses
and CNAs. Specifically:
n Board staff question consumers—According to policy,
Board employees are required to obtain descriptive informa-tion
about all callers requesting public information on licen-sees
or certificate holders. Specifically, the policy states that
the caller’s name and information, such as the phone number
and reason for the public information request, should be re-corded
by the Board employee handling the call. While the
Board has implemented this policy in order to protect nurses’
and CNAs’ safety because home addresses are considered
public information when business addresses are not pro-vided,
it could serve to discourage public requests for
information. Auditor test calls confirmed this practice when
four of the five auditors were asked for the reasons they were
requesting public information.
Finding II
22
OFFICE OF THE AUDITOR GENERAL
The Board should eliminate its policy requiring that staff ask
consumers to provide their names and other descriptive in-formation.
To address safety concerns, the Board should en-sure
that nurses and CNAs are informed as to what informa-tion
is considered public, including the fact that home ad-dresses
are considered public information when business
addresses are not provided.
n Board’s phone system is difficult to use—The Board’s
phone system further impedes consumers’ access to public
information. While the Board uses an automated phone sys-tem
for routing phone calls, it is difficult to navigate, making
it hard for callers to speak with Board staff. Specifically, the
automated phone system does not contain an option clearly
intended and labeled for the general public to inquire about a
nurse’s or CNA’s record with the Board. Auditors had to
place several calls to the Board before they were able to speak
to a Board employee. For the most part, auditors’ calls were
routed to a general voicemail box where they were instructed
to leave a message and await a return call. Although one
auditor did leave a message, she never received a response.
This same auditor then had to make four separate calls to the
Board on the same day to speak with a Board employee.
To ensure that consumers have proper access to Board staff
who can handle their information requests, the Board should
consider adding an option to its automated phone system to
route the caller to a designated Board employee or adding
additional phone lines to allow for proper routing of calls. In
addition, the Board could consider establishing a customer
service unit to handle the public’s calls, including public in-formation
requests.
Board’s automated phone
system impedes access to
public information be-cause
it is difficult to
navigate.
Finding II
23
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Board should strengthen its public information policies
to guide staff in providing public information to consumers
over the telephone and in person, including providing the
number and nature of closed, dismissed, and pending com-plaints
and disciplinary actions.
2. The Board should train staff on how to appropriately provide
public information to consumers by phone and in person.
3. The Board should eliminate its restrictive policies requiring
staff to obtain the names and other descriptive information of
consumers requesting public information.
4. The Board should ensure that nurses and CNAs know what
information is considered public, including the fact that
home addresses are considered public information when
business addresses are not provided.
5. The Board should develop and implement a plan to route
public calls, such as adding a public information option to its
automated phone system, adding additional phone lines, or
establishing a customer service unit to handle consumer
information requests.
24
OFFICE OF THE AUDITOR GENERAL
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25
OFFICE OF THE AUDITOR GENERAL
OTHER PERTINENT INFORMATION
During the audit and in response to legislative inquiries, other
pertinent information was gathered regarding the appropriate-ness
of the Board of Nursing regulating certified nursing assis-tants.
Regulating Certified
Nursing Assistants
In response to federal requirements, the State began regulating
certified nursing assistants (CNAs) in 1990. While the federal
government established minimum standards for regulating
nursing assistants, Arizona expanded its CNA regulation re-quirements.
Regulation by the Board of Nursing is one of three
primary CNA regulatory structures employed by the 50 states.
Although the Board has struggled with this responsibility in the
past, its years of experience in certifying nursing assistants and
current resource levels should enable it to more efficiently and
effectively manage this responsibility in the future.
Since 1990, the Board of Nursing has been responsible for certify-ing
nursing assistants in the
State. As illustrated in Item 4,
nursing assistants provide a
wide variety of personal care
services through daily con-tact
with patients under
medical care and long-term
care facility residents. The
Board approves training pro-grams,
maintains a register of
CNAs, conducts background
checks on certification candi-dates,
and investigates com-plaints
against CNAs.
Item 4: Nursing
Assistants’ Duties
Nursing assistants provide assis-tance
with personal care such as:
n Bathing
n Dressing
n Walking
n Meal Preparation
n Feeding
These nursing-related services are
provided to patients in facilities and
to individuals in their own homes.
The Board has been re-sponsible
for certifying
nursing assistants since
1990.
Other Pertinent Information
26
OFFICE OF THE AUDITOR GENERAL
During fiscal year 2000, the Board reports receiving 3,963 appli-cations
for certification and over 1,000 complaints against CNAs.
Further, during that same year, the Board adjudicated 323 cases
that resulted in 111 disciplinary actions against CNAs. As of July
2001, there are approximately 18,600 CNAs listed in the register.
Federal and state requirements for CNA regulation—The regula-tion
of nursing assistants resulted from the federal government’s
1987 Omnibus Reconciliation Act (Act). Through this Act, the
federal government intended to protect individuals in nursing
homes and other federally funded long-term care settings from
improperly trained nursing assistants. In addition to requiring
states to certify nursing assistants working in Medicare-certified
long-term care facilities, the Act specified several minimum certi-fication
requirements.1 Specifically, the Act requires that 1) nurs-ing
assistants working in federally funded long-term care facili-ties
receive a minimum of 75 hours of standardized education; 2)
states maintain a registry of nursing assistants who have ob-tained
this training; and 3) the states investigate complaints of
abuse, neglect, or misappropriation of nursing home residents’
property. To help offset the costs of regulating CNAs, the Act
provides federal monies to the states. In fiscal year 2001, the
Board received approximately $365,000 from the federal gov-ernment
to regulate CNAs. However, the Act does not permit
states to charge a fee to nursing assistants in order to become cer-tified.
Arizona has established certification and regulatory require-ments
for nursing assistants that are more strict than those re-quired
by the federal government. Specifically, Arizona nursing
assistants must obtain at least 120 hours of standardized educa-tion
in order to qualify for certification. In addition, the State has
the authority to investigate and take disciplinary action against
certified nursing assistants who violate any provisions of Ari-zona’s
Nurse Practice Act. Finally, Arizona nursing assistants
seeking certification must submit to a criminal background
check, and the Board must deny certification to individuals with
1 Medicare-certified long-term care facilities include nursing homes, home
health agencies, and hospice agencies. The federal government mandates
that these facilities utilize CNAs.
A federal act requires all
states to certify nursing as-sistants
working in federally
funded long-term care set-tings.
Arizona’s nursing assis-tant
certification and
regulatory requirements
are more strict than the
federal minimum re-quirements.
Other Pertinent Information
27
OFFICE OF THE AUDITOR GENERAL
felony convictions who have not received an absolute discharge
from the convictions five or more years prior to applying for cer-tification.
Nursing boards one of three primary CNA regulatory struc-tures—
Auditors’ review of CNA regulation in each of the 50
states found that it is not unusual for CNAs to be regulated
through boards of nursing, health facility regulatory agencies, or
occupational licensing and regulatory agencies. Through this re-view,
the following three predominant regulatory structures
were identified:
n Boards of Nursing—In addition to Arizona, 13 other states
regulate CNAs through boards of nursing. While some of
these boards are responsible for maintaining only their state’s
CNA registry, many others, such as Arizona’s and Oregon’s
Board of Nursing, are responsible for certifying applicants,
investigating complaints, and approving training programs.
A benefit of regulating CNAs through boards of nursing is
that nurses and CNAs typically work together closely. Fur-ther,
boards of nursing already have an established system
for licensing and regulating similar professionals. Addition-ally,
the career track for CNAs leads some to become LPNs
or RNs and having them regulated by the same board makes
the licensing transition easier.
n Health Facility Regulatory Agencies—Twenty-nine states
regulate CNAs through agencies that also regulate health fa-cilities,
including long-term care facilities. For example, Indi-ana
regulates CNAs through its Department of Health, Divi-sion
of Long-Term Care. An advantage of regulating CNAs
through this model is that the facilities these agencies regu-late
typically employ CNAs. Therefore, these agencies have
experience in regulating the settings CNAs work in and have
knowledge of CNA duties and practices. In addition, these
agencies typically have extensive experience with federal
programs and contracts.
n Occupational Licensing and Regulatory Agencies—
Finally, five states regulate CNAs along with all other regu-lated
occupations or all other medical occupations. For ex-ample,
Alaska regulates CNAs through its Division of Occu-
Arizona is 1 of 14 states
that regulate CNAs
through boards of nurs-ing.
Other Pertinent Information
28
OFFICE OF THE AUDITOR GENERAL
pational Licensing, which also regulates occupations ranging
from acupuncturists to public accountants.
Board improving its ability to effectively regulate CNAs—While
Arizona’s Board of Nursing initially struggled with the responsi-bility
of regulating CNAs, it has received additional resources
that should allow it to more effectively manage the program.
When Arizona expanded its nursing assistant certification and
regulation requirements, the Board reports that its workload ex-panded
greatly and it did not have sufficient resources to prop-erly
address this increase. Specifically, in 1995, the Board re-ceived
authority to investigate complaints alleging violations of
the Nurse Practice Act. In addition, in 1998, the Board was given
responsibility for conducting background checks on CNAs and
investigating issues arising from these checks, such as undis-closed
criminal convictions. As a result of these expanded duties
in addition to other factors, the Board was unable to conduct
timely investigations of complaints against CNAs as well as
nurses (see Finding I, pages 11 through 18). Further, the Board’s
costs to certify and regulate CNAs were higher than the federal
monies it was receiving for performing that function, and the
Board did not receive increased revenues to correspond to the
increase in its regulatory responsibilities.
However, the Board has addressed some of its CNA regulation
challenges which, according to a Board official, should enable it
to better manage its CNA responsibilities within a year. Specifi-cally:
n Board received additional investigation resources—In
fiscal year 2001, the Board requested and the Legislature ap-proved
additional funding from the Board of Nursing Fund
for the Board to hire additional investigators to help elimi-nate
its large number of investigations. The Board now has
nine investigators who specialize in CNA-related investiga-tions,
although four are temporary positions that will termi-nate
in June 2002. In contrast, the Board had only one investi-gator
specializing in CNA cases prior to 1997.
n Board received additional monies—The Board has also
received additional monies to help offset its CNA regulatory
costs. In 1997, the Board added a $40 fee for an optional card
The Board has received
additional resources to
help it better manage its
CNA responsibilities.
Other Pertinent Information
29
OFFICE OF THE AUDITOR GENERAL
that CNAs can purchase to carry as proof of current certifica-tion.
Other nonappropriated monies, including these fees,
provide over $341,000 of the Board’s approximately $1.1 mil-lion
in CNA-related funding for fiscal year 2000. Further, the
Board received a $320,000 General Fund appropriation dur-ing
fiscal year 2000 to finance fingerprinting charges for re-quired
background checks. The Board will also receive
$132,000 in General Fund appropriations during both fiscal
years 2002 and 2003 for CNA fingerprinting.
30
OFFICE OF THE AUDITOR GENERAL
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31
OFFICE OF THE AUDITOR GENERAL
SUNSET FACTORS
In accordance with A.R.S. §41-2954, the Legislature should con-sider
the following 12 factors in determining whether the Ari-zona
State Board of Nursing (Board) should be continued or
terminated.
1. The objective and purpose of establishing the Board.
The Board was established in 1921 and its mission is to
protect the public’s health and welfare by overseeing and
ensuring the safe practice of nurses and nursing assis-tants.
To accomplish this mission, the Board established
goals addressing educational standards, the licensing and
regulation of nurses and nursing assistants, the approval
of nursing and nursing assistant programs, and the pro-vision
of a nondisciplinary program for chemically de-pendent
nurses.
In support of the Board’s mission and goals, the following
essential functions are carried out:
n Licensing—The Board licenses and certifies ap-proximately
75,000 individuals, including registered
nurses, licensed practical nurses, and certified nursing
assistants. In addition, the Board approves and over-sees
nursing and nursing assistant training programs.
n Investigation—The Board has the authority to inves-tigate
complaints against nurses and CNAs from the
public and on its own initiative. The Board also con-ducts
background checks on new applicants for licen-sure
or certification.
n Adjudication—The Board conducts hearings to re-solve
violations of the Nurse Practice Act by nurses
and CNAs.
Sunset Factors
32
OFFICE OF THE AUDITOR GENERAL
n Public Information—The Board provides informa-tion
to the public on nurses and CNAs.
2. The effectiveness with which the Board has met its
objective and purpose and the efficiency with which
it has operated.
The Board performs many of its responsibilities efficiently
and effectively, but could improve its performance in
other areas. Specifically, the Board issues licenses and cer-tificates
in a timely manner to qualified candidates. In
addition, the Board actively monitors Nurse Practice Act
violators to ensure they are fulfilling all stipulations of
their disciplinary agreements. The Board also operates a
program to assist chemically addicted nurses to facilitate
their rehabilitation and recovery. Further, auditors’ re-view
of 30 complaint investigations presented to the
Board for adjudication in fiscal year 2000 found that the
Board took appropriate disciplinary action when viola-tions
of the Nurse Practice Act were substantiated, and is-sued
Letters of Concern when violations were not sub-stantiated
but the Board had concerns about a nurse’s
conduct.
However, the Board needs to improve its efficiency and
effectiveness by investigating complaints in a timely
manner. Specifically, the audit found that factors, such as
an increase in workload, have hampered the Board’s abil-ity
to investigate complaints in a timely manner. To im-prove
its investigation timeliness, the Board should de-velop
time frames for each stage of its investigation proc-ess
and generate management reports on the status of
open investigations. Further, the Board should monitor
its plan for eliminating the large number of open investi-gations
using recently acquired additional investigator
positions (see Finding I, pages 11 through 18).
Sunset Factors
33
OFFICE OF THE AUDITOR GENERAL
3. The extent to which the Board has operated within
the public interest.
The Board has operated in the public interest in some ar-eas,
but can improve in others. Specifically, the Board ap-propriately
allows complainants to participate in all as-pects
of the complaint adjudication process. The Board
also publishes quarterly newsletters, which provide in-formation
on the Board’s most recent disciplinary actions
against nurses and CNAs as well as information on perti-nent
Board issues. This information is also available on
the Board’s Web site. Additionally, the Board sets aside
time at its meetings to address questions from the public,
including visiting nursing students.
However, the Board’s public information policies and
practices should be strengthened to ensure that consum-ers
have appropriate access to public information on
nurses and CNAs. Specifically, the Board’s policy is un-clear
as to how public information requests on dismissed
or closed complaints and disciplinary histories should be
handled. Therefore, the Board should strengthen its poli-cies
to outline what records and information should be
provided in response to public information requests on
nurses or CNAs with dismissed, pending, or closed com-plaints,
including the number and nature of dismissed
complaints and the resolution of closed complaints. Fur-ther,
the Board should eliminate its policy requiring that
staff ask consumers to provide their names and other de-scriptive
information when requesting public information
and simplify telephone access to Board staff who can
handle public information requests (see Finding II, pages
19 through 23).
4. The extent to which rules adopted by the Board are
consistent with the legislative mandate.
The Governor’s Regulatory Review Council (GRRC) ana-lyzed
the Board’s five-year rule review report in August
1997 and determined that the Board had adopted most of
the rules required by statute. However, GRRC found that
Sunset Factors
34
OFFICE OF THE AUDITOR GENERAL
18 of the Board’s rules were inconsistent with statute, in-cluding
the Board’s rules addressing licensing time
frames. The Board has since amended its rules regarding
licensure and certification time frames and licensure re-quirements.
However, changes to rules regarding train-ing
program approval and regulation have not yet been
made. The Board’s rules are due for review again in Au-gust
2001.
5. The extent to which the Board has encouraged input
from the public before adopting its rules, and the e x-tent
to which it has informed the public as to its ac-tions
and their expected impact on the public.
According to the Board, it has encouraged public input in
drafting its proposed rules. For example, the Board seeks
input from stakeholder groups such as the Arizona
Nurses Association. The Board also posts its hearing
agendas, which include time that has been set aside for
public input on rules, on its Web site and publishes no-tices
regarding proposed rule changes in its newsletter.
Further, the Board sends letters regarding proposed rule
changes to various stakeholders, such as nursing execu-tives,
who may be interested in the proposed changes.
Additionally, the Board has complied with the State’s
open meeting laws by posting public meeting notices at
least 24 hours in advance at the required location, making
agendas available to the public, maintaining meeting
minutes, and having the required statement of where
meeting notices will be posted on file with the Secretary
of State.
6. The extent to which the Board has been able to in-vestigate
and resolve complaints that are within its
jurisdiction.
The Board has sufficient statutory authority and discipli-nary
options to investigate and adjudicate complaints.
However, the Board is unable to investigate complaints in
a timely manner because of its increased workload dur-
Sunset Factors
35
OFFICE OF THE AUDITOR GENERAL
ing the past several years due to its expanded CNA regu-latory
duties, inadequate monitoring of complaint inves-tigation
progress, and the high turnover of investigative
staff that it experienced in 1999 and 2000. Specifically, a
review of 83 complaint investigations found that
investigation time frames ranged from 32 days to 1,938
days, with over half the cases taking at least 360 days to
investigate. While the Board has added investigative staff
to help address the large number of open complaints, it
should also establish investigation process time frames
and generate management reports that would enable
greater oversight of open investigations (see Finding I,
pages 11 through 18).
7. The extent to which the Attorney General or any other
applicable agency of state government has the au-thority
to prosecute actions under the enabling legis-lation.
A.R.S. §41-192 authorizes the Attorney General’s Office to
prosecute actions and represent the Board. Four assistant
attorneys general currently represent the Board.
8. The extent to which the Board has addressed defi-ciencies
in its enabling statutes which prevent it from
fulfilling its statutory mandate.
Numerous changes have been made to the Board’s stat-utes
in recent years, some of which have enhanced the
Board’s ability to fulfill its statutory mandate. For exam-ple:
n Laws 2001, Chapter 101 enacted a nurse licensure
compact, allowing RNs and LPNs licensed in other
compact states to practice in Arizona without obtain-ing
an Arizona license, beginning in July 2002.
n Laws 1999, Chapters 221 and 229 gave the Board au-thority
to impose civil penalties on CNAs and sus-pend
their certificates. Additionally, legislation passed
Sunset Factors
36
OFFICE OF THE AUDITOR GENERAL
changing the two-year renewal of RN/LPN licenses
to a four-year renewal period.
n Laws 1998, Chapter 84 gave the Board the authority to
require fingerprints and criminal histories of all nurse
licensure applicants. Further, the general require-ments
for licensure or certification were increased by
requiring the Board to deny licensure or certification
to individuals with felony convictions who have not
received an absolute discharge from the conviction
five or more years prior to applying for licensure or
certification.
n Laws 1997, Chapter 140 gave the Board the authority
to issue nondisciplinary Letters of Concern to CNAs.
For the 2002 legislative session, the Board plans to request
changes to the Nurse Practice Act. For example, because
of the enactment of a nurse licensure compact in 2001, the
Board would like to make changes to the Nurse Practice
Act to align it with the compact’s language.
9. The extent to which changes are necessary in the
laws of the Board to adequately comply with the fac-tors
listed in the Sunset law.
Based on audit work, no legislative changes are recom-mended.
10. The extent to which termination of the Board would
significantly harm the public health, safety, or wel-fare.
Terminating the Board would harm the public’s health,
safety, and welfare because the Board is responsible for li-censing,
investigating, and adjudicating complaints
against RNs, LPNs, and CNAs. Without the Board’s regu-latory
activities to ensure educational and competency
standards, the public could be subject to untrained and
unskilled nursing practices. Currently, all 50 states regu-
Sunset Factors
37
OFFICE OF THE AUDITOR GENERAL
late the nursing practice and federal regulations mandate
that the State maintain a register of CNAs.
11. The extent to which the level of regulation exercised
by the Board is appropriate and whether less or more
stringent levels of regulation would be appropriate.
The audit found that the current level of regulation exer-cised
by the Board of Nursing is appropriate.
12. The extent to which the Board has used private con-tractors
in the performance of its duties and how e f-fective
use of private contractors could be accom-plished.
The Board has made use of private contractors to perform
certain services. For example, the Board contracts with a
private company to administer its CNA certification
exam. Additionally, the Board contracts for its computer
support, maintenance, and Web site needs. Finally, the
Board contracts with a firm to manage the production
and distribution of the Board’s newsletter. Currently,
there do not appear to be any further opportunities to
contract services.
38
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
OFFICE OF THE AUDITOR GENERAL
AGENCY RESPONSE
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
Jane Dee Hull Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1651 East Morten, Suite 210
Phoenix. AZ 85020-4613
Phone (602) 331-8111 Fax (602) 906-9365
E-Mail: arizona@azbn.org
Website: www.azboardofnursing.org
F:\PAD\PDF Reports\2001 Reports\01-21\Final Response to SunsetAudit 2001.doc
September 7, 2001
Debbie Davenport, Auditor General
State of Arizona
Office of the Auditor General
2910 N. 44th Street, #410
Phoenix, Arizona 85018
Enclosed is the Arizona State Board of Nursing response to the sunset performance audit
completed August 31, 2001. As requested, a formal response to each recommendation contained
within the revised preliminary report is provided.
We have valued an external review of our effectiveness and efficiency as well as citing
accomplishments over the past five years. On behalf of the agency, we wish to thank the Auditor
General and staff for their professionalism when analyzing the overall performance of the Board of
Nursing. We stand ready to provide you with an implementation status report as requested.
For the Board,
Joey Ridenour, RN MN
Executive Director
Summary Response to Performance Audit
Arizona State Board of Nursing (Report Highlights)
The number of open complaints is approximately 1,750 cases of the 9,839 total cases
received at the Board from January 1996 to August 2001. In 2000, a three- year
analysis of completed investigations identified approximately 67% of the cases
investigated resulted in no discipline being imposed by the Board and 33% resulted in
disciplinary action for violations of the Nurse Practice Act. The Board has approved
policies over the past three years to improve utilization of investigative resources by
focusing on conduct assessed to be high risk or harm to the public. Cases considered
to be no or low public risk are now resolved through policies and processes adopted by
the Board; i.e. Case Disposition Criteria, Summary Letters of Concern and Triage
Criteria for Opening Investigations.
The 83 complaint investigations listed represent 2% of the 2,052 cases finalized in fiscal
year 2000. The average cycle times for all 2,052 investigations for all categories is:
RN/LPN 9 months and Certified Nursing Assistants 10 months.
The Board performance in tracking complaints and cycle times has been in place since
1997. Effective management oversight is evidenced by a 60% increase in cases to the
Board i.e. monthly average of 95 cases in 1997 to 160 cases 2001. In 1997, the eight
Nurse Consultants averaged 3.7 cases per month versus a 300% increase in fiscal year
2000 for an average of 11 cases per month.
Improved tracking and oversight of investigations was evidenced at the June 2001
meeting when the Board was presented with 357 cases (including investigations and
other items requiring Board action), which is the largest volume of cases to be heard in
the Board’s eighty-year history. Due to time factors, fifty-eight cases were tabled to the
meeting scheduled five weeks later and completed at that time.
In fiscal year 2000, the Board received four written reports on the investigations and
progress made in reducing the cycle times. The Board continues to receive quarterly
updates.
Finding I: The Board Should Improve the Timeliness of Its Complaint
Investigations
1. The Board should monitor the progress made by its additional investigator
FTE’s toward meeting performance goals.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Performance standards for number of cases to Board per
month were implemented over three years ago and all staff has been continuously
monitored for achievement of results. The additional funding for seven temporary and
two permanent positions approved by the Joint Legislative Budget Committee in FY
2001 was data driven and formulated based on the prior four-year data on investigator
performance outcomes.
2. The Board should establish internal time frames for each phase of its
investigations, with the total number of days from complaint receipt through
adjudication being no longer than 180 days.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. The six-month goal for completion of investigations was set by
the Board in February 2000 with continuous monitoring of progress to date. Average
cycle times for RN/LPN investigations is 9 months and Certified Nursing Assistants is 10
months.
3. While working to clear its open investigations, the Board should ensure that,
at a minimum, all priority 1 investigations adhere to the established investigation
process time frames.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff.
4. The Board should generate management reports that track the status of
open complaint investigations.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Monitoring of open cases will include prescribed days for each
phase of the investigative process but the focus will continue to be on results per
investigator as cases are decided by Board action.
5. The Board should consider options, such as dividing into two panels or
subcommittees to review complaints or meeting more frequently, in order to
adjudicate in a timely manner the increased number of complaints likely to be
brought before it.
The finding of the Auditor General is agreed to and the audit recommendation was
implemented before the recommendation was made. The Board increased the annual
meeting days from 16 to 22 at the August 2001 Board Meeting.
Finding II: Board Practices Restrict Access to Public Information
1. The Board should strengthen its public information policies to guide staff in
providing public information to consumers over the telephone and in person,
including providing the number and nature of closed, dismissed, and pending
complaints and disciplinary actions.
The finding of the Auditor General is agreed to and the audit recommendation will
be implemented for all staff based on guidance from the Attorney Generals Office.
Public access to information is determined by the public records act, advice from the
Assistant Attorney General and approval of these policies by the Board. To ensure
licensee/certificate holders due process rights are protected, details of the investigative
information is considered confidential and is not released to the public until the Board
determines that a violation of the Nurse Practice Act has occurred and that discipline
may be imposed and notices are served. Federal regulations prohibit finger print criminal
history information obtained from the DPS/FBI from being secondarily released to the
public. The Assistant Attorney General is developing a draft policy regarding public
access to criminal history information, which will be presented to the Board for their
approval.
The preferred route for the majority of the public who accesses public information is
through the automated systems such as the Interactive Voice Recognition (IVR) and
Board web site available 24 hours per day. The Board currently receives an average of
1050 phone calls daily or over 288,000 annually. Over 800 of the daily calls are
members of the public directly accessing the Interactive Voice Recognition System by
entering a social security or license/certificate number to determine if an individual has an
active license or certificate, if there is a pending complaint or investigation and if there is
any disciplinary action currently imposed.
The public may also access licensee/certificate holder disciplinary actions imposed since
April 1996 through the Board’s web site. Over 1050 RN/LPNs and approximately 460
Certified Nursing Assistants have had disciplinary actions taken during the last five
years. This same public information is available through the quarterly publications of the
Arizona State Board of Nursing Newsletters sent to over 90,000
RN/LPN/CNA/student nurses in Arizona.
The Board also notifies national disciplinary data banks of disciplinary actions taken to
further protect the public. The data banks include the National Council of State Boards
of Nursing Nursys Data Bank, Health Integrity Protection Data Bank and the National
Practitioner Data Bank.
2. The Board should train staff on how to appropriately provide public
information to consumers by phone and in person.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. Seventy per cent of the 1050 daily calls are routed through
and automated system to verify licenses/certificates and determine if there is a
complaint received or investigation pending.
3. The Board should eliminate its restrictive policies requiring staff to obtain
the names and other descriptive information of consumers requesting public
information
The finding of the Auditor General is agreed to and the audit recommendation has
previously been implemented for all staff.
4. The Board should ensure that nurses and CNAs know what information is
considered public, including the fact that home address are considered public
information when business addresses are not provided.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. This information was previously provided in the Quarterly
ASBN Newsletter sent out to approximately 90,000 RN/LPN/CNA/Student Nurses
in the state. The information will be repeated in future editions as well as application
instructions.
5. The Board should develop and implement a plan to route public calls, such
as adding a public information option to its automated phone system, adding
additional phone lines, or establishing a customer service unit to handle
consumer information requests.
The finding of the Auditor General is agreed to and the audit recommendation will be
implemented for all staff. A consultant has already begun work to evaluate the phone
system and submit recommendations for improving the board functions. We welcome
suggestions to improve responding to the high volume of calls and making the system
more customer friendly.
Other Performance Audit Reports Issued Within
the Last 12 Months
01-10
Future Performance Audit Reports
Arizona Department of Corrections—Arizona Correctional Industries
Department of Building and Fire Safety
01-1 Department of Economic Security—
Child Support Enforcement
01-2 Department of Economic Security—
Healthy Families Program
01-3 Arizona Department of Public
Safety—Drug Abuse Resistance
Education (D.A.R.E.) Program
01-4 Arizona Department of
Corrections—Human Resources
Management
01-5 Arizona Department of Public
Safety—Telecommunications
Bureau
01-6 Board of Osteopathic Examiners in
Medicine and Surgery
01-7 Arizona Department
of Corrections—Support Services
01-8 Arizona Game and Fish Commission
and Department—Wildlife
Management Program
01-9 Arizona Game and Fish
Commission—Heritage Fund
01-10 Department of Public Safety—
Licensing Bureau
01-11 Arizona Commission on the Arts
01-12 Board of Chiropractic Examiners
01-13 Arizona Department of
Corrections—Private Prisons
01-14 Arizona Automobile Theft
Authority
01-15 Department of Real Estate
01-16 Department of Veterans’ Services
Arizona State Veteran Home,
Veterans’ Conservatorship/
Guardianship Program, and
Veterans’ Services Program
01-17 Arizona Board of Dispensing
Opticians
01-18 Arizona Department of Correct-ions—
Administrative Services
and Information Technology
01-19 Arizona Department of Education—
Early Childhood Block Grant
01-20 Department of Public Safety—
Highway Patrol